Our Vision:

To lead out-of-hospital community healthcare

Pro Active Care Homes:

Improving Patient

Outcomes and Care

Christopher Haigh

CLCH Care Homes Medicine

Management Pharmacist

• Background to Project

• Pharmacist Involvement in Project

• Results and Evaluation

• Lessons Learned

• Summary

Plan

2

The Project

3

• The project includes 19 care homes across H&F and West London with around 1000 residents

• It includes a range of service providers including: Extra care, Residential and Nursing Homes. The project aims to:

• Standardise care provision, improving equity of care, • Target causes of non elective preventable acute Accident and Emergency

attendances, and • Ensure a consistent skill set within care home staff by means of

identifying and meeting training needs.

• The project facilitates monthly MDT meetings within Care Homes that include representation from: Primary Care, Physiotherapy, Pharmacy, Mental Health, Social Care, Palliative Care, Community Nursing and Care Home staff members.

• Training is also provided to Care Home staff members for needs that are identified.

• In addition, some direct services such as assessment, reviews (including medication reviews) are provided to residents by members of the multidisciplinary team.

Project KPIs

4

Medicines Optimisation

KPIs

5

Medicines Optimisation service

K1 Initiation of bone health optimisation medicines

No. of residents on bone optimisation medicines who are suitable

100% Audit needs to be place in care home

K2 Reduction in medication errors No. of medication errors Reduction from baseline (TBD)

Audit needs to be place in care home

K3 Pharmacist presence at MDT meetings

Attendance at monthly MDT meetings for all homes

Pharmacist to attend at least 90% of meetings

Audit at end of pilot

K4 Medication Reviews to rationalise medications, improve patients’ conditions, increase patient safety and minimise risk

-No. of pharmaceutical interventions made by pharmacist -no. of medicines stopped/started

-cost of medicines stopped/started

Increase from baseline (TBD)

Audit at end of pilot

K6 Support care home teams to manage their medicine stock levels effectively and reduce waste

Cost of medicines waste per patient

Reduction from baseline

Audit needs to be in place for care home

K7 Care homes to receive medicines management training

No of MM sessions delivered

Dependent on need

Audit at end of pilot

K8 Improved core team skills and capability

Staff competency, rating in key areas such as falls, medicines management, infection prevention, care planning

Move from low to medium or medium to high (TBD)

Workforce audit

MDT Model

6

GP Review with Care

Home Team

Resident

MDT Meeting

Proactive Care Team

Community Nurse MDTs identify service need early intervention provided

Community Psychiatric Nurse Program to mentor carers to review all Mental Health care plans

Consultant Geriatrician & Consultant Psychiatrist Primarily input to MDT

General Practitioner Some GPs have elected to do ward round with MDT staff

Pharmacy All Residents have received a medication Review (1000+)

Physiotherapy Average 10 new assessments and 94 follow up / month

Social Worker Greater Safeguarding Awareness 96+ CH staff trained

Trinity Hospice Lead in relation to advanced care planning

Partnership

Model works with eight existing providers across NHS, Social Care and Voluntary sector

Liaison with Community service providers has improved

Learning

Learning from this project is also contributed to whole systems redesign via Putting Patients

First and Out Of Hospital committees

Final results to be published as academic paper to share

learning

Clinical Medication Reviews and Optimisation of Patients Treatment.

• Level 3 clinical reviews were carried out face to face in the homes by an 8a pharmacist

and adjustments made via the GP based on this.

• Primary focus was clinical but we also implemented cost saving strategies

Reduce Medication Errors

• Errors were followed up with the relevant parties to ensure necessary amendments were

made

• Education and training to prevent further errors.

Reduce Medicines Wastage

• All homes audited for medication waste at the start of the project and at the end.

• Clinical pharmacist reviewed the ordering processes in each home and identified where

this could be reduced.

• Unnecessary medications were stopped as part of the clinical review.

Pharmacy Input

7

Education and Training

• All homes received formal training sessions on medication errors and usage.

• Informal training sessions with staff/prescribers when a need was identified.

MDT Monthly Attendance and Multi-Disciplinary Working.

• The pharmacists took a leading role in the MDT’s pushing the direction of care and

ensuring that medicines optimisation took an important role in the care setting for the

patients in the homes.

• Close working relationships were formed with other professionals such as physio’s and

elderly care consultants

• Residents could be referred to each other if potential issues for the other professional

were noted by anyone.

Joint Rounds/Visits with GPs

• The clinical pharmacists would work closely with the GPs and often do joint visits and

medication review rounds at the homes

Pharmacy Input (cont.)

8

• Statistical Process Control was applied to data collected directly from the homes

• SPC works on the principle that a process is predictable and that there will be routine

variation within limits.

• Anything occurring outside the natural process limit indicates a change has occurred

• Data collection for the project evaluation began in June 2014 and the final report is

currently being written

• SPC will tell us when a trend has changed, not specifically what caused the change in the

trend

• Not a double blind control trial – difficult for multivariate model to isolate factors proving

causation

• Adjustments for seasonal Variations not possible until 2-years worth of data available in

April 2014.

Evaluation - SPC

9

SPC - Example

10

0

20

40

60

80

100

01/0

4/20

13

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9/20

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01/1

0/20

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01/1

1/20

13

01/1

2/20

13

01/0

1/20

14

01/0

2/20

14

01/0

3/20

14

01/0

4/20

14

01/0

5/20

14

01/0

6/20

14

01/0

7/20

14

01/0

8/20

14

01/0

9/20

14

01/1

0/20

14

01/1

1/20

14

01/1

2/20

14

H&F Total Falls (GDS)

H&F Total Falls (GDS) Average

Lower Natural Process Limit Upper Natural Process Limit

Results

11

0

50

100

150

200

250

300Ap

r-13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-1

4

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Falls

H&F WL Grand Total

Falls Change

Apr

13/14

May

13/14

Jun

13/14

Jul

13/14

Aug

13/14

Sep

13/14

Oct

13/14

Nov

13/14

Dec

13/14 Total

Change -29 -46 -18 -31 -14 -44 -68 -42 3 -289

% Change -29.59% -42.99% -24.32% -34.07% -16.28% -48.35% -56.20% -45.65% 4.62% -35.03%

Results

12

0

10

20

30

40

50

60

70

80

Apr-1

3

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-1

4

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

LAS From Falls

H&F WL Grand Total

LAS From

Falls

Apr

13/14

May

13/14

Jun

13/14

Jul

13/14

Aug

13/14

Sep

13/14

Oct

13/14

Nov

13/14

Dec

13/14 Total

Change 3 -6 -1 -5 -1 -3 -21 -12 5 -41

% Change 21.43% -42.86% -8.33% -29.41% -6.25% -13.64% -61.76% -54.55% 62.50% -25.79%

Results

13

0

20

40

60

80

100

120

140Ap

r-13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-1

4

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

LAS Call Outs

H&F WL Grand Total

LAS Call Outs

Apr

13/14

May

13/14

Jun

13/14

Jul

13/14

Aug

13/14

Sep

13/14

Oct

13/14

Nov

13/14

Dec

13/14 Total

Change 5 4 -3 -4 7 4 -35 -21 15 -28

% Change 19.23% 12.50% -11.54% -12.90% 26.92% 13.79% -59.32% -53.85% 83.33% -9.79%

Results

14

0

10

20

30

40

50

60

70

80

90

100Ap

r-13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-1

4

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

A&E Attendance

H&F WL Grand Total

A&E

Attendance

Apr

13/14

May

13/14

Jun

13/14

Jul

13/14

Aug

13/14

Sep

13/14

Oct

13/14

Nov

13/14

Dec

13/14 Total

Change 5 -3 -2 1 -1 3 -31 -15 9 -34

% Change 29.41% -10.71% -10.00% 4.17% -4.35% 15.00% -72.09% -51.72% 90.00% -15.89%

Results

15

0

5

10

15

20

25

30

35

40

Apr-1

3

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct-1

3

Nov-

13

Dec-

13

Jan-

14

Feb-

14

Mar

-14

Apr-1

4

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct-1

4

Nov-

14

Dec-

14

Admissions

H&F WL Grand Total

Admissions

Apr

13/14

May

13/14

Jun

13/14

Jul

13/14

Aug

13/14

Sep

13/14

Oct

13/14

Nov

13/14

Dec

13/14 Total

Change -3 2 -5 1 6 -1 -12 -1 9 -4

% Change -23.08% 18.18% -41.67% 9.09% 66.67% -7.14% -63.16% -6.67% 300.00% -3.74%

Results – Individual

Homes SPC

16

Positive Change Negative Change No Change

Falls 8 4 5

LAS Call Outs 7 4 4

LAS Call Outs

from Falls

3 1 6

A&E Attendance 4 3 4

Hospital

Admissions

3 0 5

Safeguarding

Alerts

1 0 4

Out of Hours Call

Outs

5 1 4

• Qualitative Evaluation of the Project

• The Final Project Evaluation will include:

– Interviews with residents and carers

– Statistical Process Control (SPC) will be used to identify changes in

trends in the areas of LAS call outs, A&E attendance, Falls, Hospital

Admission and Hospital Readmission

– Board interviews, document analysis and observation of board

meetings

– Interviews with care home, health & social care staff

– Staff survey to measure change in self reported competency

– Interviews with health and social care professionals

– Non-participant observation in care homes (including care

coordination meetings, day-to-day practice, ward rounds and staff

training programmes)

CLAHRC Evaluation

17

• In addition to the KPIs, SPC and CLAHRC evaluation the pharmacy team recorded all

interventions made.

• Cost savings calculated for drug’s started, stopped or amended

• All interventions graded from I-V depending upon clinical significance

• Grading completed by pharmacist completing log, discussion between pharmacists only

on significance of intervention.

• Potential to apply University of Sheffield1 methodology to add cost/QALY value based

upon this grading system but value may be less accurate in primary care.

1 A systematic review of the effectiveness and cost effectiveness of interventions aimed at preventing medication error (medicines reconciliation) at

hospital admission, The University of Sheffield, School of Health and Related Research. (ScHARR), 2007. Commissioned by NICE

Pharmacist Data

18

Results

19

I - Non-Clinical Reason for the intervention 438 6.8%

II - Minor benefit to patient care 1209 18.9% 25.7% IIIa - An incident or situation which could have led to an increased

length of stay or care was prevented or improved upon 3354 52.4% 70.8% IIIb - A change was made to ensure that evidence-based standards

of treatment and/or clinical protocols were followed 1176 18.4%

IV - Reversible harm or admission to hospital 220 3.4% 3.5%

V - Averted Death or major permanent harm 3 0.05%

Total 6400

Identified savings: Total drug cost savings for interventions (per annum) £168,661.60

Currently Accepted £106,549.11 Cost of 2 8a pharmacists* (includes on costs) £121,753.00

Additional cost of drugs started (i.e. optimise thearpeutic outcomes) £55,051.19

Net -£8,142.59

Results – ADE Cost and

QALY

20

Range of cost estimates for preventable ADEs (Adverse Drug Event) (see University of Sheffield1) QALY

Cost parameter Low Mid High Lower Higher

I - Non-Clinical Reason for the intervention £0.00 £0.00 £0.00 0 0

II - Minor benefit to patient care £0.00 £3.00 £6.00 0 0.00

IIIa - Evidence based treatment/according to Guidance £65.00 £107.50 £150.00 0.005 0.1

IIIb - Evidence based treatment/according to Guidance £65.00 £107.50 £150.00 0.005 0.1

IV - Reversible harm or admission to hospital £713.00

£1,098.50 £1,484.00 0.09 0.66

V - Averted Death or major permanent harm £1,085.00

£1,602.50 £2,120.00 0.7 18.65

1 A systematic review of the effectiveness and cost effectiveness of interventions aimed at preventing medication error (medicines reconciliation) at hospital admission, The University of Sheffield, School of Health and Related Research. (ScHARR), 2007. Commissioned by NICE

Results

21

Sum of Low Cost parameters for preventable ADEs

Sum of Mid Cost parameters for

preventable ADEs

Sum of High Cost parameters for preventable

ADEs

£405,263.00 £662,586.50 £919,910.00

Lower Higher

QALYs Gained 44.55 654.15 Cost Per QALY £2,732.95 £186.12

• NICE assumed criteria is £20,000 - £30,000 per QALY gained for funding interventions

• If ADE cost estimates used £397,121- £911,768 saving to health economy!

Results – GP action

22

2%

15%

83%

Recommendations Accepted as of Dec 14

No

TBC

Yes

Range 54-97%

• Joint GP rounds and visits lead to increased rate of action

completion

• Can’t be a single review – need follow up to implement

safely

• Face to face reviews and patient counselling led to the best

interventions

• Education and training also needed to be continual with

staff – High turnover

• Nearly all feedback from all involved was highly positive

• Direct cost savings vary, cost neutral to low cost

• Variable input from specialist sectors – consistency was

with pharmacists and physiotherapists

• Time to effect – Rome wasn’t built in a day!

Experience

23

• The Project showed a decrease in Falls,

Ambulance Call outs and A+E attendance

• Less clear for admissions however limited data

• Best evidence for falls and which had the best

data set

• Hard evidence of improvement

• Employing pharmacists is free to low cost when

prescribing savings are calculated

• Potential for savings to health economy and QALY

gain

• Improves patients QoL!

Summary

24

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