Systemwide Improvement of Services for Older People http://www.ihi.org/knowledge/Pages/ImprovementStories/SystemwideImprovementOfServicesForOlderPeople.aspx The aim of the two-year programme was to promote independence in the London community of older people, through the delivery of person-centered, coordinated services.The specific objectives were: To identify vulnerable older people at risk in the community, using a case finding or case management approach To initiate the single assessment process (a new government led multi-agency, multidisciplinary, whole person assessment system to reduce duplication and speed processes), wherever the person enters the system To deliver coordinated services in the community To gather systematically the views of older people and caregiverIn the next few slides I will discuss the medicines-related programme.
All health and social care professionals can carry out the single assessment process (SAP). In this there are 4 trigger questions about medication. I will explain these questions in the next slide. If the answer to any of the questions is yes, the patient is referred to a specialist pharmacist for a detailed medication review. The specialist pharmacist develops a pharmaceutical care plan which is then sent to the patient’s local community pharmacist who then delivers and monitors the care plan. They may need to liaise with the patient’s GP, nurse or carer and with the care co-ordinator.If the patient does require any health or social care then their case is sent to the care co-ordinator who then co-ordinates all the communication and health and social care for that patient.
These four trigger questions can be asked by anybody in health or social care. They can even be asked in hospital during an inpatient stay.The questions address the issue of accessing medicines, adherence or compliance, day to day issues with taking medicines and clinical issues.If the answer to any of the 4 questions is yes, the patient is referred to a specialist pharmacist for a review.
Upon receipt of a referral, the specialist pharmacist requests obtain a summary of patient’s medication and health problems from the GP.The specialist pharmacist carries out a detailed review of the patients medicines.The key themes of this review are the same as the 4 trigger questions but there are detailed questions about each. In the assessment, the top three are similar to MUR but more detailed. The fourth, medication review, requires specialist clinical knowledge / training.Questions covered in Access IssuesGetting repeat prescriptions / Delivering medication to patientHas patient ever run out of medication?Compliance issuesDoes the patient need any help with taking medication?Does the patient currently have a compliance aid?Do you know/understand how to take the medicines?Day to day medication management issuesAny problems with swallowing tablets, reading labels, mobility, manual dexterityCan they instil eye drops or use inhalers properly?Clinical medication reviewConsider appropriateness of each medication (indication, dose, ADR, drug interaction, monitoring)Consider patient’s medical conditions (untreated condition, drug use without indication)
The role of the community pharmacist is crucial here.The pharmacist will not only be delivering the care plan in a practical way but also monitoring this plan. In the programme follow-up was after 6 months but it can be more frequently.Monitoring and review are very important because they give patients and professionals a chance to understand what is working well and take steps to improve other aspects. This is especially important if the patient’s condition has changed since the initial review with the specialist pharmacist.
This project has already shown some positive results with reduced hospital and GP attendances. The improved communication pathways have resulted in better flow of information between various agencies / professionals and therefore resulted in faster service for patients. Staff working directly with patients are able to help the patients immediately by making referrals rather than simply signposting patients to appropriate services.
A quick look at the programme again. There are several communication streams and multiple health professionals involved in the scheme.
The programmes sounds and looks very complication with multiple professionals and referral or communication pathways. It is important to get the communication pathways clear to prevent failure. Forms may be posted, faxed, emailed between agencies, but there should be feedback/acknowledgement mechanism in place too.The role of the care co-ordinator is vital as they are co-ordinating both the health and social care for the patient.Staff training is required to ensure these new roles can be fulfilled. So staff should be trained on how to ask the 4 trigger questions and refer.Pharmacists will need to be trained to develop care plans and packages. It is also important to understand the time required to performs these additional tasks and this will have resource implications. Such a system relies on complex communication and trained staff and most importantly the care co-ordinator. There should be plans in place for continued safe service during these systems failures.
Communication of medication changes across interfaces is a well recognised issue within the NHS. Whenever a patient transfers care settings there is a risk that information about their medicines is not transferred, or inaccurately transferred.My Medication Passport is a written record of a patient's medicines. My Medication Passport was launched on 17 April 2013 The medication passport is designed to help the patient and anyone involved in the patient’s care to understand their current medication and changes to it and what the cannot take.It should be shown to the GP, pharmacist, dentist or any other healthcare professional involved in provision of care. It should be presented at outpatient appointments and at A&E attendances.The passport has been given to over 5000 patients across Imperial College Healthcare NHS Trust with excellent feedback. The plan is now to make the passport available across the wider area of North West London and then potentially further afield.
It is designed to improve communication between patients, carers and healthcare professionals and maintain a record of changes made to the patient's medication. Features of the medication passport include:Relevant information about the patient and his/her GPList of medicines that the patient cannot take and the reasons whyCompliance aids in useList of the patient's current medicines List of changes to medicinesWhat are the aims?The passport aims are to help patients/carers have a complete record of their medicines as well as an understanding of the reasons for any changes being made to their medicines. It's designed to empower patients/carers to take control of their medication and help seamless transfer of medication information across healthcare interfaces.Passports are available in two formats:As a paper based booklet As an app for iPhone or Android phones
It lists patient’s medication as well as medication that the patient cannot take. Recent changes to medication are also documented so health professionals can get a brief medication history.Available as a booklet or App – it is useful for patients of all ages, especially those who have and know how to use Smart Phones. Information is instantly accessible.Because all medication is listed clearly, it avoids problems during transfer e.g. when patients go to hospitals or see another health professionals. Health professionals can check the patient’s medication list and prescribe new medicines that do not interact with the current medicines. During outpatient clinic appointments at the hospital, this is very important as the Drs don’t always have a list of the patient’s regular medication when they see the patient.This booklet could also be adapted to include other information that is relevant to the patient e.g. the contact name and number of their specialist nurse, carers etc. and this will allow better communication between professionals without having to go to the GP each time.
A booklet just for medicines will increase the amount of medicines-related documents/paperwork that patients have to carry with them. Patients on warfarin have yellow anti-coagulation booklets, those on insulin have the insulin passport.It may be worth if we could have a booklet that had space to add these other documents.Will patients carry their booklets / passports. The App is a good idea and can be used if people have smart phones. We could wait to see what the response is from the Imperial project.Will healthcare staff use the booklet. At the moment, staff write in other patient records (e.g. medical notes) but on patient-held information. Staff training and commitment are also required. Also need to include hospital staff who may prescribe/change medication. They should be documenting their actions in the booklet too.There is a cost associated with these and the scheme should only be commissioned if there is significant commitment from all parties to use the booklet at all times.
Workshop 2: Benchmarking solutions showcase
Benchmarking solutions showcase13 June 2013
1. London Older Peoples Service DevelopmentProgramme2. My Medication Passport3. Optimize Adherence ServiceCurrent solutions
1. London Older Peoples ServiceDevelopment Programme
London Older Peoples Service DevelopmentProgramme, Lelly Oboh, April 2003Aim• to promote independence among olderpeople, through the delivery of person-centered, coordinated servicesLOPSDP medicines management pilot
LOPSDP medicines management pilotPatient Case SelectionSocial services staff, Nurses,Occupational therapists, etcInitiate Single AssessmentProcess (SAP)4 questions about medicinesSocial services or health staffContinued CareCase manager or care coordinator(health or social service staff)The Medicines Management ProjectIn-depth Medication Assessment &Pharmaceutical Care PlanSpecialist PharmacistProvide Pharmaceutical Care PackageCommunity PharmacistNurse GP CarerLondon Older PeopleProgramReferral PathwayAdapted from: Lelly Oboh, LOPSDP, The ‘Medicines Management’ Project, (January to July 2003)
Single Assessment Process (SAP)4 questions about medicinesArea of Concern Single Assessment Process (SAP) QuestionsAccess issuesQ1. I need help getting a regular supply of mymedicines.Compliance issuesQ2. Sometimes I do not take my medicines the waythat the doctor wants.Day to day medicinesmanagement issuesQ3. There are some medicines that I cannot get out oftheir containers.Clinical issuesQ4. Realistically, I think some of the medicines that Itake could work better.
In depth medicines assessment byspecialist pharmacistArea of Concern Example QuestionsAccess issues Has you ever run out of medication?Compliance issuesDo you need any help taking medication?Do you use a compliance aid e.g. blister pack?Day to day medicinesmanagement issuesCan you use your inhaler properly?Can you open and remove medicines from a blisterpack?Clinical issuesPharmacist assesses the safety and appropriateness ofmedication.
Care Plan delivered and monitored bycommunity pharmacistPatients name: DOB: Assessed by Date: Tel:PHARMACEUTICAL NEEDSIDENTIFIEDPLANANTICIPATED OUTCOMESAND ACTIONAccess issues e.g. repeatprescription collectionPatient does not run outof medicinesCompliance and day-to-daymedicines managementissuese.g. medicationprovided in easy-openbottlesPatient able to takemedicinesClinical issues (Identify theproblem or risk involvingmedication, includingfailure to prescribe for ancondition)e.g. liaise with GP /diabetes specialistnurse for blood glucosemonitoringGood blood glucosecontrol and medicationused to get maximumbenefit for the patient
LOPSDP pilot - benefits• number of hospital and GP attendances• waiting times & speeded service delivery• Developed joint training & multi-skilling• Improved information & improvedprocesses• Empowered front-line staffLOPSDP pilot - benefits
LOPSDP medicines management pilotPatient Case SelectionSocial servicesstaff, Nurses, Occupationaltherapists, etcInitiate Single AssessmentProcess (SAP)4 questions about medicinesSocial services or health staffContinued CareCase manager or care coordinator(health or social service staff)The Medicines Management ProjectIn-depth Medication Assessment &Pharmaceutical Care PlanSpecialist PharmacistProvide Pharmaceutical Care PackageCommunity PharmacistNurse GP CarerLondon Older PeopleProgramReferral PathwayAdapted from: Lelly Oboh, LOPSDP, The ‘Medicines Management’ Project, (January to July 2003)
LOPSDP pilot - considerations• Sounds complicated: multiple professions andreferrals• Role of care co-ordinator vital• Communication pathways to be established• Training staff to understand the 4 triggerquestions and carry out reviews• Time constraints• Backup plans for IT failure / lack of trainedstaffLOPSDP pilot - considerations
Imperial College - My Medication Passport• Basic rules about medicines• Contact details - Patient, GP and communitypharmacist• List of allergies / medicines that can’t be taken• List of medication aids• Medicines reminder chart• List of changes to medication and reasonsImperial College - My Medication Passport
Imperial College - My Medication PassportBenefits• Concise list of patients’ medication• Booklet or App (available on phone, computer)• medication-related problems during transferof care e.g. allergies, interactions• Adapt to include other information e.g.contacts of diabetes specialist nurse, carer etc.Imperial College - My Medication Passport
Imperial College - My Medication PassportConsiderations• Too many pieces of paper / information e.g.warfarin booklet, steroid card, insulin passport.– Can we place them all together?• Will patients / healthcare staff use the passport?• Cost of booklets and implementationImperial College - My Medication Passport
Optimize -A Medicines AdherenceSolutionprovided byGreen Light Pharmacyin it’s Stepney branchcommissioned byTower Hamlets PCT in2012 & now by NHS England
There is no impending pharmaceuticaldiscovery, surgical innovation orgovernmental policy change with greaterpotential for improving the health ofpatients and efficiency of the health caresystem, than simply increasing thepercentage of treatment plans thatpatients (are able to) carry out asprescribed[Align Map www.alignmap.com ]
“Drugs don’t work in patients who don’t take them” C. Everett Koop M.D – Surgeon GeneralUSA 1982-89It is estimated that 50% of all prescribed medication is not used by patientsas intended by the prescriber [ Sackett D.L., Snow J.C. “The Magnitude of Compliance & Non-Compliance” In:Haynes R.B. et al (Eds) “Compliance in Health Care” Baltimore, John Hopkins University Press 1979; Nov 22]It has been estimated that between 20 and 50% of patients are notadherent to their medication regimeKripalani S, Yao X, Haynes RB. Interventions to Enhancemedication Adherence in Chronic Medical Conditions: A systemic Review. Archives of Internal medicine 2007; 167:540-550Improving medicine taking may have a far greater impact on clinicaloutcomes than an improvement in treatments Haynes R.B., Ackloo E., Sahota N., McDonaldH., Yao X. “Interventions for Enhancing Medication Adherence” Cochrane Database System Review 2008; (CD0000011)33-69% of all medicine related hospital admissions are due to poormedication adherenceOsterberg & Blaschke. New England Journal of Medicine 2005 Vol 353Only 4 to 21% of patients are receiving the optimum benefit from theirmedicines Garfield S, Barber N, Walley P, Willson A, Eliasson L. Quality of Medication Use in Primary Care - Mapping theProblems, Working to a Solution: A Systemic Review of the Literature. BMC Medicine 2009; 7:50
• To support independent living• To improve patient adherence with therapy by– Improving understanding– Identifying practical problems– Supporting the carer• To reduce wastage and thus make cost savings by decreasingthe local prescribing budget• To help people manage their medicines safely & appropriately• To decrease Preventable Medication Related HospitalAdmissions and thus make cost savings to the CCG’s HospitalAdmissions budget
The service focuses onimproving, supporting & monitoringadherence (how people take theirmeds) not simply on the provision ofcompliance devices (ie not just ablister pack, other solutions as well)
Optimize:A MedicinesAdherenceSolutionReferralAdherenceAssessment byAccreditedCPSupport Plan &Report (SPAR), carriedout by patient’s usual,localCP.(Compliance aids;cognitive support;use of MAR sheets;reminders/prompts)Discharge fromservice, butwith on-goingSupport PlanReview(initiallyat 3months, then every6 months)Evaluationof ReferralbyAccreditedCommunityPharmacist(CP)Patient referred to other health & socialcare services and/or contacted byaccredited pharmacist to discuss thereason for the referral and possiblesolutions.InappropriateReferralAppropriateReferralAdherence Evaluation by AccreditedCP (usually as a domiciliary visit)Adherence MUR Plus by AccreditedCPSupport PlanCommunicated to thepatient, as userfriendly (patient held)Medicines PassportPatient carrieson in the serviceAnnual Report &Evaluation of Serviceto Commissioner byService Provider
Unused Meds, collected from just ONEpatient, prior to joining Optimizeservice
Evaluation of DataDue end July 2013 (from 1st six months ofservice)Evaluation will be supported by UCL