Summary of the example
The Northumbria Shine project showed that when you undertake a patient-centred review of medicines in a care home setting, you not only improve quality and safety but can release healthcare resources and funding.
A pharmacist undertook detailed medication reviews using primary care records and the results were discussed at a multidisciplinary team (MDT) meeting involving the care home nurse and the resident’s general practitioner (GP), with input from the local psychiatry of old age service (POAS) where appropriate.
Suggestions for medicines which should be stopped, changed or started, and other interventions (eg monitoring) were discussed with the resident and/or their family.
The project developed a pragmatic approach to optimising medicines in care homes while involving all residents in decision making and managed to stop one-in-five medicines because they were either no longer indicated, unsafe or the patient made an informed decision not to take the medicine.
The net saving per person reviewed against the medicines budget was £184 per year.
Why we think it’s important
Seventy percent of care home residents experience at least one medication error. In addition 50% of medicines are not taken as prescribed, with adverse drug reactions contributing to 17% of all hospital admissions.
Residents in care homes are older and frailer than the general population and more likely to be prescribed multiple medicines therefore more susceptible to adverse events yet often have little involvement in these prescribing decisions.
Learn more about the example
Aims and objectives of the work
Shine aimed to ensure care home residents were appropriately prescribed the medication they were currently taking.
- undertake detailed care home medication reviews,
- question the appropriateness of prescribing
- ensure that all medicines prescribed have a clear and documented indication,
- ensure that all prescribed medicines are safe and clinically beneficial.
The intervention had three main components: a review of medicines by clinical pharmacists, a MDT discussion and resident (and/or family) involvement. During medication review process, the following questions were considered:
- Is the medication currently indicated?
- Is the medication still appropriate, taking into account co-morbidities?
- What are the resident’s (or family/carers’) views?
- Are medicines missing that the patient should be taking?
The results of the medication review were discussed within a MDT including the clinical pharmacist, care home nurse, general medical practitioner, psychiatry of old age consultant, and POAS staff. The final decisions were made jointly with the resident (or their family) where possible. All residents were monitored for adverse events by care home staff following the intervention and followed up by the pharmacist. The process was iterative, with rapid feedback from each clinic used to improve the process.
A four level resident involvement framework was developed:
- Assume capacity and involve resident
- Where resident lacks such capacity, ask family member to be involved
- Where the family member is unable to attend contact via telephone (including one Skype call to Australia) or by letter
- Where the resident has no family or significant friends, seek independent advocates.
Over several cycles four potential models of working with GPs were developed:
- GP attended the MDT, joint decisions made with the care home nurse and pharmacist
- Interventions discussed with the GP after pharmacist review and prior to the MDT
- Interventions discussed with the GP following the MDT but prior to resident involvement
- No GP involvement, prescribing pharmacist leads the process. Interventions recorded in the general practice electronic notes, GPs could challenge the interventions.
Twelve care homes had full reviews; 8 additional homes were partially reviewed. Fifteen homes were mixed nursing/residential; 3 residential only, and 2 nursing only.
- In total 422 residents were reviewed (in 16 practices)
- 1,346 interventions were made; 52.3% were to stop medicines
- 17.4% of 3,602 medicines were stopped
- Reasons for stopping medicines included no current indication (57%) or residents’ request (17%)
- 41 medicines (6%) were stopped because of safety concerns
- 9 residents (2.1%) experienced potential adverse events following changes. All events were reversible and did not result in harm
- 57 residents (16%) were fully involved in decisions about medicines, families were involved for 137 residents (39%) and letters were sent to families of 141 (40%) residents
- Savings against the medicines budget were £77,703 per year or £184 per person
- The intervention cost was £32,670 (calculated using pharmacist, GP, POAS and care home nurse time) for 422 patients
- On average one hour of nursing time per day was released from the medicines round and reinvested into patient care
- Medicines returned to community pharmacies for destruction decreased
Key observations and lessons
- A targeted communications strategy ensured maximum exposure of the project
- A wide steering group ensured that all relevant professionals and patients were represented
- The clinical pharmacists involved were experienced independent prescribers competent to make autonomous decisions
- Core members of a MDT were the pharmacist and the care home nurse
- The POAS consultant and team were fully dedicated with built in capacity to manage the additional workload
- Care home nurses and general practices were supportive and allowed full access to medical records
- One approach could not be sustained across all the practices
Links to the final report and a paper published in BMJ Quality Improvement are below.
National guidance, data and publications
The Care Home Use of Medicines Study (CHUMS) demonstrated that two thirds of care home residents were exposed to at least one error with an 8-10% chance of an error in the processes of prescribing, dispensing or administration of medicines.
A report into medicines management in care homes by Age UK and the Health Foundation identified many deficiencies including excess prescribing.
In 2014 NICE issued guidance on managing medicines in care homes which included recommendations for good practice on the systems and processes.
In 2016 the Royal Pharmaceutical Society issued guidance for the pharmacy profession.
Links to these various background resources are provided below.