We helped one of GP federations come up with scheme to invest £100K in medicines management to create a win-win-win. Better for the patients, practices and CCG.
We had the article below – co-authored by Jo Goodwin and Dr Neil Paul published in the Commissioning Review Magazine.
Locally our population is living longer and growing older, which is a good thing, however as a consequence the number of frail elderly especially those in nursing or care homes has also gone up creating more workload. For the last few years our CCG has run a nursing home scheme, paying practices to enhance the care they give to patients in nursing home. This scheme is driven by an understanding that these patients are high cost not only in terms of GP time but in terms of referrals, prescribing and in emergency admissions. The theory is by targeting these patients we can save the local health economy a lot of money and deliver high quality care.
Below we describe an innovative project that our practices, who are part of a not for profit GP federation, undertook, that we think has interesting outcomes in the hope that it might help other areas.
In essence with the CCGs help and assistance, we top sliced some of the money from the nursing home scheme to spend on pharmacist reviews of both, patients in all care homes (nursing and residential) and the care homes themselves. We present a range of findings, some conclusions and some recommendations.
In South Cheshire, all 18 practices helped by Howbeck Healthcare ltd, joined together about 18 months ago to form a not for profit GP Federation whose main aims are:
- To improve services to patients
- To find new income sources/streams for practices
- To help find productivity gains and generate savings through innovation
- To standardise and harmonise the delivery of care across member practices
We have been quite successful winning £1.9M in PMCF Wave 2 funding, £300K in “pharmacist in practice” funds and over £500K in other projects including a winter pressures scheme that was judged to have been economically successful.
Our CCG (South Cheshire) have been very supportive of our Federation and spoke to the directors and lead GPs about the proposed care home scheme on how to get the most from it in terms of care given and outcomes achieved, including financial savings.
The federation GPs considered some of the problems associated with care home patients. Across the patch we had a variety of methods of dealing with homes. In some areas one practice looked after the whole home and had a dedicated doctor who did regular ward rounds in some areas all the pts were registered with different practices and they were called depending on who was ill. There was little appetite in those practices who didn’t do much care home work to take a home and off the record we were told this was because even with the additional payment per patient the work was considered very demanding and onerous especially if done correctly. Many practices felt they couldn’t cope even with extra funded work as they were struggling to deliver their normal services. Recruitment being a major issue. Bearing this in mind we came up with the idea to utilise skill mix and outside resource to reduce the burden of work on local GPs, whilst hopefully achieving cost savings from quality work.
We came up with the idea of top-slicing £100K from the care home incentive scheme budget and spending it on hiring in help. The natural option was to go with pharmacists partly as we locally are very pro pharmacist (we have just recruited 7 pharmacists to work in local practices under the national pilot scheme) and because there were companies available that we had good relationships with, who had staff who could do this work at short notice.
We split the project into three;
- A detailed medication review for each patient in the home.
- A supportive audit of the home itself – looking at policies, procedures and practices.
- A regular visit from a pharmacy technician for each home to provide support with medicines management
Being an independent company the GP federation didn’t have to tender or go through complicated procurement procedures. We sought out local companies who were involved in this area and put our ideas to them. It soon became clear there were 2 ideal candidates.
- Moston Pharmacy Services could do the audits and technician visits
- Interface Clinical Services (ICS) could do the medication reviews.
It is worth mentioning no one involved in the project and indeed no member of the federation had any interest or commission deal with either of these companies.
Practice signup was always going to be key to this succeeding and we needed to convince them this was taking a lot of work off them not just money. Luckily they agreed, after discussion, that it would make their lives easier; it would help them hit their prescribing targets, their quality measures, and hopefully reduce hassle in their surgeries as medication queries from homes has been identified as a large time burden on practices.
Summary Detail of the interventions
The service overview from ICS included reducing inappropriate prescribing, addressing concordance issues, structured medicines management support around long term conditions, full risk stratification of all pts with aim to reduce admissions/exacerbations and reducing potential harm from medicines.
The ICS Pharmacist met with each practice to agree the flow of information. A level 2 medication review was carried out by accessing the patient’s records either at the practice or via EMIS remote. This identified missing blood monitoring and any issues to discuss with the patient/carer/GP. The pharmacist then visited the home to complete the full clinical medication review and brought back any recommendations to the practice to discuss with the Lead GP. This either involved a face to face discussion with the GP or a list of recommendations was left for review. Any agreed changes were implemented by the pharmacist or the practice.
For the clinical audits, Moston designed an audit which encompassed all aspects of clinical medicines management and associated activities within a Care Home setting. The structure of the audits was based on the National Institute for Health and Care Excellence (NICE) Guidelines, Managing Medicines in Care Homes published in March 2014*.
Moston also arranged for a pharmacy technician to visit the care homes on a monthly basis to support homes by doing a full stock check, identifying surplus stock, strength/dose optimising medication and identifying non-formulary items.
Clinical Medication reviews
- 996 patients had a medication review – only 60% of these patients had a medication review coded in the previous 12 months.
- 11544 medication items were reviewed – 12.8% of these had an issue/intervention recommended
- 62% of recommendations were agreed and implemented at the practice follow up visit – some recommendations were left with the GP to review at a later date so this figure may actually be higher
- 61% of high risk drugs did not have the correct monitoring completed
There were high levels of polypharmacy – 91.8% of patients were taking >4 medications. Generally polypharmacy (>4-5 meds) is appropriate, however, 61.7% of patients were taking ≥10 medications (‘hyperpolypharmacy’). A person taking ≥10 medications is 300% more likely to be admitted to hospital*.
The project identified 5.5% of items recommended to stop. They also addressed unmet need and started a number of patients on calcium/vitamin D supplements and anticoagulants, for example, with the potential to reduce hospital admissions for fracture and stroke.
15% of patients had an Anticholinergic burden score of 4 or more. It’s thought that a higher anticholinergic burden may increase the risk of cognitive impairment and death*.
Savings reported to date for the scheme are in excess of £52.5K from drug costs alone. No quantification has been made of possible reduced admissions.
32 care homes were visited by the pharmacy technicians. £8k annual potential savings were identified within the first couple of monthly visits. Surplus stock was identified to the value of £3.5k. We believe this to be an underestimate as some homes reported having a ‘clear out’ ahead of the visit.
Of the observations recorded, errors on the MAR sheets was the most common (12% of the items reviewed). 9% of items were handwritten on the MAR sheets so were open to transcription errors. Time savings were identified, for example there was a lack of knowledge of the storage requirements for the different schedules of controlled drugs in some homes, which was causing unnecessary work.
32 homes received a full day audit. The top 3 major observations were:
- Medication not stored at recommended temperatures in 28% of homes
- 50% of the homes did not retain complete oversight of the ordering process which could lead to medicines waste
- 25% of homes had inadequate or out of date policies
Homes with a single aligned GP surgery appeared to have less communication issues, more streamlined processes for medication supply and a more time efficient use of all parties (GP/Care Home/Pharmacy) leading to the provision of a better service to residents within the home.
The findings support regular clinical medication review and clinical pharmacist visits to our care homes. This should include reducing inappropriate polypharmacy, providing medicines optimisation for long-term conditions and reducing anticholinergic burden.
GP Practices should ensure robust systems are in place for high risk drug monitoring. Regular searches are being developed to support this locally.
The audit findings support the model of one GP practice looking after all residents in the care home. There was better communication and more streamlined processes where this was in place. The CCG care home scheme for this year aims to achieve this model across South Cheshire.
A weekly visit by the GP for all care homes is recommended. Nursing homes seem to get this as standard, but residential homes may need more support. Again, this year’s care home scheme encourages this.
Improving access to education for the care home staff, particularly in standalone homes.
The care home must receive a copy of the monthly prescriptions from the pharmacy as soon as they draw them down from the Electronic Prescription Service (EPS). This should reduce time taken to chase up missing items by all parties and ultimately reduce wastage of unwanted medication.
There is an opportunity to reduce wastage by increased oversight of the ordering process, the introduction of a more robust stock management and medication audit processes, more accurate prescribing quantities and improved communication across the GP practice, care home and pharmacy.
The knowledge/understanding gap relating to the requirement for correct storage of medication and the implications if this is not adhered to could be easily addressed via a step by step guide of how to remain compliant with the manufacturer’s recommendations and what to do if there is a breach.
There is a need for constant review of the MAR sheet information to reduce the potential for dosing errors. Homes should work with their pharmacy to reduce the number of hand written alterations needing to be made to MAR sheets.
Communication of recommendations from the pharmacy technician visits to the practices and pharmacies was difficult due to information governance. If we were to run the scheme again the one thing we would change would be to reduce the frequency of the pharmacy technician visits and ensure they had a point of contact in each practice to liaise with regarding any issues or recommendations.
It’s the Authors’ feeling that the £100K invested in this scheme was worthwhile. It generated £52.5K of direct savings some ongoing and potentially large savings in indirect costs such as admissions, referrals and workload for GP practices. Further ongoing cost savings are expected as the scheme identified areas for quality improvement which should reduce medicines waste.
It would be great to have a face to face clinical medication review with each resident and their family, carer, GP and Clinical Pharmacist to meet the patient’s goals.
It would make sense to try to use once daily dosing where possible. The audits identified a large proportion of time was spent on administering medicines. Reducing the frequency of the drugs round would free up more time for providing care. Standardising the type of blood glucose machine and inhaler devices would mean less training needed for staff.
The pharmacy technician visits highlighted the high number of medicines related queries the care home staff had. Providing access to a regular pharmacy team member to help answer these queries would support the home and its residents.
We plan to work with our local authority and CCG to use our findings to support our care homes and patients.
Moston saw many examples of best practice during their audits which they are keen to share with all the homes. They have collated the best practice points as a support tool to improve medicines management. Sharing of this information across the Care Homes in the area will improve the quality of care to residents, the communication between various parties and increase compliance with current legislation and guidance.
We are happy to be contacted to discuss this more fully.