The project is improving the quality of life for care home residents by reducing avoidable hospital admissions, through comprehensive clinical medication reviews.
A proactive approach is adopted to identify patients at risk of hospital admission and reduce this risk by assessing pharmaceutical issues that may contribute to an emergency NHS service call out. A large part of the care home pharmacy team's routine medicines optimisation work involves addressing inappropriate polypharmacy and challenging clinicians to de-prescribe.
CCG surveillance of service call out data by care homes and increased avoidable admissions to the acute hospital trust identified a need for increased clinical support in elderly care homes. In 2015, the CCG multi-disciplinary Care Home Improvement Team was established to help reduce avoidable hospital admissions. Pharmacists were to support homes by conducting medication reviews and systems and process reviews, while nurses offered education and training, support for proactive care planning and collaborative working with other care services.
Support from the small Care Home Pharmacist team is prioritised to those care homes which have the highest emergency service call outs and admission to hospital. Homes are ranked on their admissions from the preceding year and those homes with highest admission rates are targeted first. In addition, the Care Home Pharmacists may target homes which receive a very low Care Quality Commission (CQC) rating overall or where significant concerns are raised in year. Our innovative and reproducible methods for targeting homes allows us to generate a return on investment that is high. Our methods could be adopted by others which would add value across the UK to the benefit of many more care home residents.
Our pharmacy team works closely with colleagues at neighbouring East and North Hertfordshire Clinical Commissioning Group who were involved with NHS England Care Homes (vanguard) project which was to provide planned, proactive and preventative support to elderly care home residents with complex care needs. We have adapted aspects of their model to suit the resources we have, which was initially 1 working time equivalent (WTE) Care Home Pharmacist in August 2015, rising to a total of 3 WTE Care Home Pharmacists in January 2017. Our 3 x WTE pharmacists (graded at band 8a) cost approximately £150,000 per year.
The NHS Sustainability and Transformation Plan for Hertfordshire and West Essex consist of 3 CCG areas: Herts Valleys CCG, East and North Hertfordshire CCG and West Essex CCG. All three CCGs have a small care home team working to optimise medicines. We all collaborate and share working methods thereby refining and improving practice. Shared learning across our teams and learning from others is a key component of how we continuously strive to make patient specific improvements. This approach leads to increased reductions in hospitalisation. Our service continuously evolves and develops as staff mould into these expert roles. We accept comment and criticism from all our stakeholders including patients, carers, care home nurses, GPs, safeguarding staff, council staff and our peers across the country doing similar roles. As a result we continuously develop our service to try to make it as high quality as we can. This has enabled us to get superb buy-in from many outside the medicines optimisation team on the value added nature of this project and is allowing us to further extend the team in 2018/19.
Within selected care homes, pharmacists target their medication reviews to those residents at high risk of admission to hospital. These residents are identified by the carers, GPs and Care Home Pharmacists. For instance, residents with inappropriate polypharmacy, frequent hospitalisation, taking high risk medicines and experiencing compliance issues would have their medicines reviewed.
Prior to starting reviews we arrange an introductory meeting with the care home managers and specialist staff that are involved with the medicines management. We describe the aims of our service to benefit the residents and their carers. In terms of consent, we are able to exercise common law and we explain that as Care Home Pharmacists, we act on behalf of the GPs to provide direct care. Care home managers are requested to inform residents and family members about the service and it is possible to opt out if desired. To reinforce these messages, we have recently developed an information leaflet which describes the medication review for patients and relatives. We also display a poster whilst working in the home to state we are present and can be approached at any time for more information.
Contact is made with the supplying community pharmacy. Again, we summarise the aims of our service and engage with them to aid with the medication reviews. It is essential that the community pharmacist has a copy of the individual pharmaceutical care plan in order to implement any medication changes safely.
The process for an individual patient review involves various steps as outlined below:
In order to capture and analyse pharmaceutical interventions from the medication reviews, the adapted Rio scoring tool is used1. It is a simplified health intervention scoring tool that is a qualitative assessment of the potential impact of each intervention, allowing the assignment of a value of likelihood with regard to the prospect of the intervention preventing hospital admission. The tool is not a validated tool; it was initially adapted by NHS Croydon CCG and is used in other UK CCGs as the best available method for assessing the likelihood that an intervention might prevent an admission.
Rio score 1 is assigned where there is no likelihood of hospital admission had the action/advice not taken place and an example of this would be stopping a vitamin supplement as the resident's diet has improved whilst living in the care home.
Rio score 2 is assigned where hospital admission is possible had the action/advice not taken place. An example of this would be gradually withdrawing a historic tricyclic antidepressant prescription as the resident's mood has improved since moving to the care home which will reduce anticholinergic burden and reduce their falls risk.
Rio score 3 is assigned where hospital admission is likely had the action/advice not taken place and an example of this would be reducing the dose of a direct oral anticoagulant due to impaired renal function, in order to prevent a major bleed.
The local cost avoidance figure of £2705 is attributed to each hospital admission avoided. This is based on the average cost of a hospital admission or accident and emergency attendance (A&E) for a patient over 75 years to the local acute Trust in 2016/17. The figure used in each CCG in the STP is generated locally by an analysis of the costs of local admissions in the previous financial year. It is re-calculated annually for each CCG within our STP. Since each CCG uses a local figure, the cost-avoidance figure used varies.
We have used an adapted Croydon CCG method(1) for our hospital scoring and savings:
(1) Jesson, B. and Williams, V. Capturing and Analysing Clinical Interventions: Capturing and Analysing Clinical Interventions. sps.nhs.uk. 2015. https://www.sps.nhs.uk/wp-content/uploads/2017/08/Croydon-explantory-doc.pdf (accessed 13 Jul 2018).
Patients:
Patients have a better quality of life as medication review can empower patients and improve activities of daily living. These benefits can be observed by carers, relatives and the patients themselves, thereby enhancing their NHS experience. Preventing hospital admissions can avert a whole host of problems. There is evidence that entry to hospital in general can be debilitating for elderly patients, and it can take many weeks or months after a hospital admission for an elderly person to return to their previous state of health. Through remaining at home, residents are able to maintain their resilience to minor stressors, such as urinary tract infections, and are more likely to recover to their previous level of health. The psychological consequences of a hospital admission, such as loss of confidence and independence, are also avoided.
Relatives:
It can be stressful for a relative who lives in a care home to be admitted to a hospital. Relatives are comforted by a reduced level of stress and anxiety that comes with having a family member being cared for within the home, avoiding the need for admissions. Relatives feel more confident that their family members are receiving holistic care in the home. There are fewer disruptions to relatives' daily lives as time is saved rearranging personal commitments in order to visit their family member in hospital or assist as next of kin.
Nurses/Carers:
Carers and nurses can be assured that their excellent care has contributed to avoidance of a hospital admission. Their work is acknowledged by managers and they receive the gratitude and praise they deserve. Carers directly observe the resident and as the number of hospital admissions reduce, they are able to witness the resident remain in good health and not experience the challenges of returning from hospital and the lengthy recovery time.
GP:
There are fewer GP call outs because ailments can be managed in house. This saves times for GPs and instils confidence in the care provided. By reducing the number of hospital admissions, there are fewer transitions in care settings which minimises the risk of communication lapses that may occur at the interface. From a medication point of view, by preventing hospitalisation, there are fewer chances of medication discrepancies as hospital reconciliation is not required.
Acute Hospital:
The acute hospital benefits from fewer A&E attendances/admissions thereby crucially preserving bed space. Care home residents are often very complex in nature, with a huge number and range of co-morbidities. Therefore they are highly complex and extremely time-consuming to get a full overview of all their issues on a standard medical ward. By care home patients remaining in their familiar environment, it frees up the specialist services to manage their acute case-load in a more efficient way, while keeping the patient in a setting where their full background is known.
Care Home:
As avoidable hospital admissions are reduced, a higher standard of care is delivered and this is recognised by organisations such as CQC and the local council where their contract lies. Fewer hospital admissions means time is saved as staff do not need to be released from the care home to re-assess at discharge whether the resident's needs have changed due to hospitalisation. Care home providers and managers note better staff retention and boosted morale which is essential in such a care setting.
County council:
The county council benefits because if the residents avoid hospital admissions and stay in good health, there is a knock on positive effect for government funded social care. For example, by reducing the risk of a fall and subsequent hospitalisation through medication review, a reduced level of social care is required as that resident's care needs will not increase and therefore the ratio of carers to this particular resident and the associated cost of this will also not increase.
CCG:
By investing in a team of pharmacists in care homes, to make quality interventions, standards of care are raised reducing the reputational risk of catastrophic failures of care, which can be very public and damaging. Through shared learning, stronger relationships can be built between CCGs of the STP as care home teams support one another. Emergency services are used more appropriately and this results in a reduced number of costly service call outs. Many CCGs are prioritising reducing avoidable hospital admissions, so these posts support these organisational objectives. The savings made from reduction in admissions and reduced prescribing are significant and contribute to the CCG savings plans.
The outcomes of the project are to improve quality of life of patients by reducing avoidable hospital admissions.
In the financial year of 2017/18, 3 WTE Care Home Pharmacists reviewed 749 patients and reviewed 8439 medicines in total. We were able to achieve significant hospital admissions avoidance savings by working collaboratively with residents, care home staff and GPs to ensure that our service focussed on reducing avoidable admissions. 1925 interventions were agreed of which 221 were classed as Rio score 3 and 614 Rio score 2, resulting in a total hospital admissions avoidance saving of £736,000. See the Care Home Pharmacist 2017/18 Report attached. We were able challenge GPs to de-prescribe medicines and achieved £130,000 in direct drug savings. 15% of all medicines reviewed were de-prescribed; 12% were stopped and 3% of medicines' dosages reduced.
Quality of life for patients has improved through a reduction in hospital admissions. For instance, by challenging inappropriate polypharmacy and scrutinising each medicine prescribed, the review enabled many non-essential medicines to be gradually de-prescribed. The residents continued to take only the most necessary medicines that would help prevent a hospital admission. Additionally, patient compliance improved as residents were able to take a more manageable number of tablets each day.
The team have produced some supportive tools for care homes such as the falls risk of commonly prescribed medicines. Carers and nurses have been able to take a proactive approach to initiate a GP medication review by utilising this tool and identifying high risk residents that take medicines with an associated falls risk. The beauty of this project is that it could be easily replicated in other areas. As our population ages, the spotlight is on elderly care and there is a big opportunity for medicines optimisation here. Resources required are small compared with the financial effects and quality impacts. The reduction in costly hospital admissions is huge.
Hospital admissions related to our target care homes have been tracked by stakeholders since the project began and there is a clear decrease in numbers. We have empowered care homes and as a result have been able to reduce clinical support to the homes. . These data add to growing evidence that demonstrates pharmacist led interventions can reduce hospital admissions. We are proud that we can demonstrate a £5 saving for every £1 invested in staff (see attached Final Care Home Pharmacist Report 2017/18, Hospital Admission Avoidance Savings graph).</p\
