This new operational model is intended to help pharmacy and medicines teams implement the NHS England and NHS Improvement Primary Care and Community Health Support for Care Homes guidance.
It describes the medicines and pharmacy contribution to the work and sets out how teams should collaborate across the NHS system. It also provides practical advice and resources and a model of service to help local systems reduce the risk of harm during the COVID-19 period by ensuring that consistent medicines and pharmacy services meet the needs of care home residents and staff. It includes an implementation plan to activate the model of service at local level.
The work is being led and coordinated in each area by a clinical lead appointed by each CCG and has the backing of the regional and national NHS England and NHS Improvement pharmacy and primary care teams.
The guidance to primary and community care providers and commissioners on 1 May 2020 set out four key areas where clinical pharmacy and medicines optimisation support is needed. The model suggests that support for care homes will require collaborative, clinical and professional leadership from across all pharmacy sectors; such as a senior pharmacy leadership group at ICS or CCG level, supported by regional chief pharmacists and regional directors of primary care.
Clinical, general practice, care homes and CCG pharmacists and pharmacy technicians, supported by specialist hospital pharmacists,and community pharmacy, are being asked to rapidly mobilise and join multidisciplinary primary and community care teams to support care homes, and implement this model.
Pharmacy leaders across the system, including hospital, community and mental health chief pharmacists, are being asked towork with each other and care home leads at CCGs and primary care networks to offer immediate pharmacy and medicines support to care home staff and residents.
Model of Service
The letter to primary care providers and commissioners from NHS England and NHS Improvement (1stMay 2020) set out four key areas where urgent clinical pharmacy and medicines optimisation support is needed.
1. facilitating medication supply to care homes, including end of life medication;
2. delivering structured medication reviews via – video or telephone consultation where appropriate – to care home residents;
3. supporting reviews of new residents or those recently discharged from hospital;
4. supporting care homes with medication queries, and facilitating their medicines needs with the wider healthcare system (e.g. through medicines ordering).
This model of service supports these four key areas, underpinned by the following six domains:
- Medicines supply
- Clinical pharmacy
- Training and education
- Local implementation
It is intended to offer a model of professional leadership, co-ordination and practical support for primary care (general practice, community pharmacy, CCG), community health services, and NHS trust pharmacy teams. Any service delivery model should reflect the PCN arrangements by default and this model could be embedded as part of local care home work streams led by PCN/ general practice clinical leads for care homes.
This matrix lists key actions that any Pharmacy and Medicines Care Home Taskforce could take, supported by the system pharmacy leadership group, to aid and monitor implementation of this model.
Clinical and Professional Leadership
Support for care homes will require collaborative, clinical and professional leadership from across pharmacy sectors; for example, through the establishment of a local chief pharmacist led, senior pharmacy leadership group that will facilitate consensus building and rapid decision making. This group would be most effective if locally determined and supported through regions. They would ideally be a tripartite arrangement involving senior pharmacy leaders from primary care (including community pharmacy), community services and secondary care (acute and mental health NHS trusts). These have already been established in many localities.
The pharmacy leadership group would want to build on pharmacy leadership arrangements for care homes where they exist or potentialy establish a COVID-19 ‘Pharmacy and Medicines Care Home Task Force’ to deliver this work linked into wider primary care and community health service support for care homes initiatives that CCGs have been asked to put in place.
NHS England and NHS Improvement regional chief pharmacists and Health Education England (HEE) pharmacy deans across the seven NHS England and NHS Improvement regions will support local senior pharmacy leadership groups, enabling learning and good practice to be shared nationally. The NHSE&I Pharmacy Integration Team will provide central support and signposting to resources based on learning from national programmes.
Resources and support for care home residents will also be provided by partner organisations and hosted on care home support hubs: NHS Specialist Pharmacy Service (SPS) and Royal Pharmaceutical Society (RPS).
A rapid local workforce strategy and action plan, facilitated by the local pharmacy leadership group, will help support the mobilisation and deployment of clinical pharmacy teams to support care homes. HEE pharmacy deans will be central to supporting the development of staff where necessary, but it is the senior pharmacy leadership group that would support,advise and oversee local staff deployment. System leadership teams may want to undertake this process to support planning and implementation of services to care homes by pharmacy teams. These planning matrices can help leadership teams rapidly understand existing provision, identify gaps and plan services locally.
The ‘Pharmacy services to care homes’ section outlines the priority areas where pharmacy teams can support care homes; local teams will find it helpful to map current service provision and workforce to their priorities. Collective professional responsibility and collaborative working will be required from local pharmacy leaders to enable staff, with the requisite skills, to work flexibly and support care staff and residents. There may also be opportunities for staff returning to the register or shielded staff to support locally.
Where existing teams do not have the capacity to support all their care homes the Pharmacy and Medicines Care Home Task Force, or equivalent, should have urgent discussions, supported by the pharmacy leadership group and HEE pharmacy deans, with local organisations to identify additional staff.
In addition to supporting local care home service provision by providing pharmacy staff (where feasible), secondary care and community services can also support care home staff and residents with access to their expertise and clinical information. Local plans should be established that facilitate access to this expertise for care home staff as well as pharmacy teams working directly with care homes.
Training and Education
All pharmacists and pharmacy technicians working with care homes will want to undertake a self-assessment to identify gaps in learning, especially for COVID-19 related clinical scenarios. A simple self-assessment process (in development) has been developed by the RPS in collaboration with the Centre for Postgraduate Pharmacy Education (CPPE).
Training resources will be hosted on this website where pharmacy professionals can update gaps in learning through rapid learning. Existing material will be used from educational partners.
Pharmacy Services to Care Homes
The following sections set out in more detail how the response to the NHS letter from 1stMay can be delivered locally. Each care home should have a nominated clinical lead and services to care homes should be delivered in partnership through network arrangements to avoid duplication and reduce infection control risks. Clinical teams should support care homes where possible, for example through the use of virtual multidisciplinary teams (MDTs).
1. Clinical support
Pharmacy teams, typically including independent prescribers, can support the clinical review of patients by working with care home clinical leads and MDTs to agree the prioritisation of residents including the following situations:
- Patients with COVID-19 symptoms (See specific advice and guidance for managing patients with COVID-19)
- Acute illness that may need changes to medicines (e.g. due to renal impairment, sick day rules)
- Optimising medicines at the end of life (e.g. prescribing and deprescribing)
- Discharge from hospital (e.g. medicines reconciliation)
- New residents: rapid clinical review (with the MDT if needed) and medicines reconciliation to optimise medicines
- Other at-risk groups (e.g. renal dysfunction, high risk medicines including insulin, anticoagulants and lithium, and falls risk). The NHS SPS hub will collate tools for all at risk groups in the Care homes: Clinical pharmacy section of this SPS care home resource hub.
2. Medicines supply
Community pharmacies will continue to lead on supply of prescribed medicines to care homes. Community pharmacists and their teams can actively work with care homes pharmacists and pharmacy technicians in all aspects of medicines supply including:
- Facilitating medication supply to care homes (especially end of life medication)
- Supporting the development of clinical hubs to supply end of life medicines, in line with local plans to support patients at the end of their life
- Supply of urgent medication
- Supporting medicine systems (e.g. electronic repeat dispensing, proxy ordering; see Care homes: Supply of medicines section on this SPS care home resource hub)
- Working with local nursing and GP teams to ensure care homes are supported with all aspects of medicines ordering
- Supporting access to medicine administration records (MAR) charts.
3. Supporting care homes with advice and support
Care home staff and residents, and the pharmacy teams supporting them, will need information and support to ensure the safe and effective use of medicines. There are a range of resources from partner organisations that can support pharmacy teams. The Pharmacy and Medicines Care Home Task Force will want to consider:
- Establishing a single point of contact for care homes for rapid advice on medicines and their use
- Engaging clinical pharmacy and medical specialists from secondary care (e.g. mental health or care of the elderly pharmacists, at consultant level where available) to support with complex patient cases
- Working with regional organisations for more complex queries (e.g. regional medicines information centres)
- Systems for documentation and transfer of information, integration with MDT record systems and follow up (if necessary) of any advice given
- Working with local NHS111/Integrated Urgent Care (IUC) service providers to identify the remote support and access to pharmacists working within the local IUC clinical assessment services (CAS) and the national Pharmacy Clinical Assessment Service (PCAS) as part of the Coronavirus CAS capability.
4. Delivering structured medication reviews
For some residents, it is still important to deliver structured medication reviews (SMRs) to ensure medicines safety. SMRs could be delivered via video or telephone consultation and where appropriate, involve residents and/or their family/carer. Local teams will want to consider priority groups, ensuring that those residents that are on high risk medicines or combinations of medicines are prioritised. Whilst it is desirable for all pharmacists undertaking SMRs to have completed or be enrolled on the CPPE 18-month training pathway, which leads to independent prescribing training, the current priority during the COVID-19 emergency demands a flexibility to provide urgent support for care home residents, including undertaking SMRs for some residents.