Summary of the example
Adhoc local CCG projects on problematic polypharmacy identified barriers of funding and resourcing for making sustainable improvements. Kent Surrey Sussex AHSN agreed to support a project focusing on the benefits of carrying out Level 3 medication reviews (the gold standard) to enable comparisons to be made between the results and outcomes of previous projects which had focused on Level 2 medication reviews.
A seven month pilot ran in Brighton and Hove CCG from August 2016 to February 2017. Holistic level 3, face to face, medication reviews were carried out in care homes and other care settings with a focus on listening and shared decision making in order to evidence cash releasing savings and improve health outcomes in this patient population. The reviews were undertaken by an experienced pharmacist and pharmacy technician working closely with GPs, hospital colleagues and Age UK.
It showed that this approach can prevent hospital admissions, offers savings to CCG prescribing budgets, and is well received by patients and carers. The findings have been used to inform Phase 2 support for similar work in a different locality. At the end of Phase 2 The AHSN will produce a toolkit that organisations can use to implement similar projects locally.
Why we think it’s important
More and more people are being diagnosed with several long term health conditions. This can lead to being prescribed multiple medicines to address each illness, but not necessarily with consideration to how the drugs work with each other. The result can be drugs cancelling each other out – losing their beneficial effects – or the patient reacting poorly to the combination of drugs, causing further health issues.
Coupled with the fact that it can be very confusing to understand how much to take of each drug and how often, the medicines are often taken incorrectly or not at all, leading to worse patient outcomes and wasting NHS resources.
The average older person is admitted to hospital taking 13 medicines and adherence is also poor resulting in significant waste of resources.
Learn more about the example
Aims and objectives of the work
By March 2018 evidence of cash releasing benefits and improvements in health outcomes from reducing levels of problematic polypharmacy by shared decision making in an agreed target population of older people across KSS.
- Identify complex older patients at risk of medicine related harm
- Carry out holistic patient centred level 3 medications review to optimise medication in order to improve patient outcomes and quality of life
- Improve communication between and integration of relevant services
- Demonstrate difference between level 1 or 2 reviews and level 3 reviews
- Quantify cash releasing savings from reducing problematic polypharmacy
- Prevent/reduce hospital admissions
- Support spread and adoption of project across additional localities in KSS
A seven month pilot ran in Brighton and Hove CCG from August 2016 aiming to reduce levels of problematic polypharmacy in older adults at risk of medication-related harm. Brighton and Hove had an established annual care home medication review service with supporting data and a comprehensive evaluation of results to date.
The AHSN funded a pharmacist and pharmacy technician to carry out Level 3 medication reviews in care homes and patient’s own homes with a focus on listening and shared decision making. Patients were identified and referred by a number of routes:
- New admissions to care homes
- Complex patients at risk of medicines related harm flagged by GP surgeries
- Patients discharged from hospital
- Patients and carers phoning Age UK Crisis Line with medication related issues
A multi-professional multi-sector Project Board met monthly to develop the project and discuss any issues that occurred through-out the pilot. It agreed appropriate referral routes and communication requirements and supported the project pharmacist and technician. Metrics were agreed and collated on an on-going basis and were fed into a collection sheet which allowed a data dashboard to be generated.
Peer to peer support was provided by a Consultant Pharmacist from NHS SPS. And there were good links into the AHSN Medicines Optimisation Network.
The multiple stakeholders provided feedback at the end of the pilot. Full stakeholder feedback is available in the accompanying report which also captures additional detail including lessons learnt and resulting recommendations. This report also includes a dasboard of final results. An evaluation booklet summarises the key findings and includes key metrics.
Key findings include:
- 86 patients were referred to the service and 59 reviews were completed (13 patients refused participation)
- 11 referrals came from Brighton and Sussex University Hospitals
- A typical review took 2.5 hours including preparation and follow up
- 115 recommendations were made to GPs, 77 were accepted.
- Savings generated included £112.54 per review (rising to £172.06 if all recommendations were actioned) and an average of £421.19 per review was saved from potential hospital admissions avoided.
- Medicines removed from patients homes were costed at £21.77.
Patient and relative feedback was overwhelming positive – with many valuing the time taken to listen and learn about their situation.
Health professionals also reported that detailed holistic reviews enabled them to influence positive change.
Having a pharmacist experienced in elderly care leading the reviews helped hospitals feel confident about discharging patients with more complex medication requirements.
All stakeholders believed this was an important and successful project and were pleased with the project outcomes. They also felt that this opportunity enabled key relationships to be built and developed where clear open lines of communication didn’t previously exist. The work also highlighted areas for development and potential ways of adjusting current services in the locality to sustain the results delivered through this pilot and better serve this population.
The KSS AHSN website has useful reports on this work – the links are below.
The website pages will be updated as the work develops.
National guidance, data and publications
Nationally there is concern about the rise in unintentional polypharmacy and the potential harm it can cause patients as well as the cost of unnecessary medication.
NICE addresses polypharmacy and in particular multi-morbidity and polypharmacy in its Guideline (56) on multimorbidity. It recommends considering an approach to care that takes account of multimorbidity in circumstances outlined in the guideline. This approach to care involves personalised assessment and the development of an individualised management plan. The aim should be to improve quality of life by reducing treatment burden, adverse events, and unplanned or uncoordinated care.
The approach takes account of the person’s individual needs, preferences for treatments, health priorities and lifestyle. It aims to improve coordination of care across services, particularly if this has become fragmented. Medicines are likely to be just one aspect of a person’s care and should not be considered in isolation
Polypharmacy is on all Regional Medicines Optimisation Committee Agendas.
The 2013 Kings Fund Report on Polypharmacy and Medicines Optimisation – making it safe and sound covers the background to why problematic polypharmacy is important; its impact and what needs to be done to improve patient’s quality of life.
Acting Director, East Anglia Medicines Information Service, Specialist Pharmacy Service