Update: NICE Managing Update: NICE Managing

Medicine Care Homes SC1 Medicine Care Homes SC1 Focus on Recommendations 1.2 & 1.15Focus on Recommendations 1.2 & 1.15

Community Health Services

East & South East England Specialist Pharmacy Services

East of England, London, SouthCentral & South East Coast

Medicines Use and Safety

Focus on Recommendations 1.2 & 1.15Focus on Recommendations 1.2 & 1.15

Lelly Oboh

Consultant Pharmacist, Care of older people

20th Nov 2014

Care homes

• Over 18,000 homes care for ~ 460,000 adults in England1

• 95% are over 65 years2 and average age is mid 80s 3

• Most common conditions � dementia, stroke, degenerative

neurological conditions, advanced cardio-respiratory disease,

cancer and painful arthritis 3

• Residents are frail, vulnerable with complex health and social

care needs and take many medicines

• Relatively short life expectancy �Av. length of stay 1-2 years

male, 2-3 years female

1. CQC.2009 The quality and capacity of adult social care services: An overview of the adult social care market in England 2008/09

2. Age UK. Later Life in the United Kingdom June 2013. accessed 12/4/14 http://www.ageuk.org.uk/Documents/EN-

GB/Factsheets/Later_Life_UK_factsheet.pdf?dtrk=true

3. British geriatric Society . Quest for quality. 2011. http://www.bgs.org.uk/campaigns/carehomes/quest_quality_care_homes.pdf

Residents have additional health needs

vs. those in domiciliary care1

• 78% had at least one form of cognitive impairment.

• 64% were “confused” or “forgetful”.

• 20% exhibited challenging behaviour.

• 19% described as depressed or agitated

• 71% were incontinent. • 71% were incontinent.

• 27% were immobile, confused and incontinent.

• 76% immobile or required assistance with mobility

• 3 x more likely to fall than those living at home and 10 x risk of hip fracture2

1.Data obtained from BGS Quest for quality 2011 (Help the Aged, Quality of life in care homes, A review of the literature, 2007, 96-97)

2. DoH 2009. Falls and factures: Effective interventions in health and social care.

www.dh.gov.uk/en/Publicationsandstatistics/Publications/dh_103146

Background

NICE Social Care Guidelines

• Since April 2013, NICE’s role expanded to include social care.

• Opportunity to apply an evidence-based system to decision-making in the social care sector

• Guidelines will promote better integration between health, public health and social care services public health and social care services

• They are not mandatory

• To be used in conjunction with existing frameworks and regulation (e.g CQC) already in place

• ‘Medicines management in care homes (CH)’ is first topic referred to NICE by DoH

• Provides practical support to improve the quality of care

• Underpin development of Quality Standards

NICE Quality Standards (QS)• Concise set of statements that describe high-priority areas for

measurable quality improvement in an area

• Support the Government's vision for a health and social care

system focused on delivering the best possible outcomes for

service users1

• Social care QS focus on the services and interventions to

support the social care needs of service users support the social care needs of service users

• Not targets, not mandatory but must be considered when

planning and delivering services�Must have a good reason to

ignore

• Aspirational, but achievable standards

1. Health and Social Care Act (2012).

NICE SC1 2014

Managing Medicines in care homes

• Audience: Health and Social care providers and

Residents should have the same involvement in

decisions and right to access appropriate services

and support as those in domiciliary care

• Audience: Health and Social care providers and

commissioners and others involved with decision-

making about medicines in CHs

• Recommendations about the systems and processes

that need to be in place to ensure the safe and

effective use of medicines for all residents

Patient centred care

Medicines related interventions must

• Take into account the individuals needs and

preferences (patient centred)

• Involve others who the patient wishes to be • Involve others who the patient wishes to be

involved

• Keep residents free from harm, abuse or

neglect (safeguarding)

NICE: 17 Recommendations

8. Medication review

9. Prescribing

10. Ordering

11. Dispensing and supply

12. Receipt storage and disposal

13. Self administration

1. Develop and review policies

for safe and effective use of

medicines

2.2. Support informed Support informed

decision makingdecision making13. Self administration

14. Administration (monitoring)

15.15. Covert administrationCovert administration16. Homely remedies

17. Training skills and

competencies of care home

staff

decision makingdecision making3. Sharing medicines

information

4. Record keeping

5. Identify, report, review and

learn from incidents

6. Safeguarding

7. Accurate medicines list

(medicine reconciliation)

Related Quality Standards

(Consultation, due Mar 2015)• Statement 1. Care homes have a medicines policy that is regularly reviewed.

• Statement 2. People who live in care homes are supported to self-administer their

medicines unless a risk assessment has indicated that they are unable to do so.

• Statement 3. People who live in care homes have an accurate listing of their

• medicines made on the day that they transfer into a care home.

• Statement 4. People who live in care homes have details of their medicines shared • Statement 4. People who live in care homes have details of their medicines shared

• with their new care provider when they move from one care setting to another.

• Statement 5. GP practices have a clear written process for prescribing medicines

for their patients who live in care homes.

• Statement 6. People who live in care homes have at least 1 multidisciplinary

medication review per year

• Statement 7. Care homes have a documented process for the

covert administration of medicines for adult residents

1.2 Supporting residents to make informed

decisions and recording these decisions• Residents have same opportunities to be involved in decisions

about their treatment/care as those in domiciliary care (HSCP)

• And they get the support they need to do so

• Prescriber or CH staff records a resident's informed consent in the care record. (consent not needed for every administration)

• CH staff record the circumstances and reasons for a refusal in record and MAR (if given) unless a pre agreed plan existsrecord and MAR (if given) unless a pre agreed plan exists

• HSCP notify prescriber and supplying pharmacist of ongoing refusals (if resident agrees).

• HSCP identify and record anything that may hinder a resident giving informed consent � considered and reviewed. – Mental health problems, lack of (mental) capacity to make decisions

– Problems with vision, hearing, reading, speaking or understanding English and cultural differences.

• HSCP: care home staff, social workers, case managers, GPs, pharmacists and community nurses

1.2 Supporting residents to make informed

decisions and recording these decisions

Prescribers should – Assume there is capacity to make decisions

– If there are any concerns about ability to give informed consent, assess resident's mental capacity in line with appropriate legislation

– Record assessment of mental capacity in the resident's care record

• HSCP to ensure that residents are involved in best interest decisions, in line with legislation

– Find out about their past and present views, wishes, feelings, beliefs and values

– Involve them, if possible, in meetings

– Talk to people who know them well, within and outside CH

Process for Involving patients in decision making about their medicines

NICE CG 76. 2009

NICE 2014

National Care Forum Patient Recordhttp://www.nationalcareforum.org.uk/medsafetyresources.asp

Example of a protocol for refused medicines

• Gives clarity about when refusal needs to addressed. And how urgent– Critical medicines– Critical medicines

– Symptomatic control, hormone replacement

– Certain drugs or all drugs

Examples of processes

• Include questions/prompts as part of

medication review process/protocol e.g.

– Can the patient be involved in decision making

process?process?

– Does the patient want to be involved?

– To what extent can they be/do they want to be

involved?

1.15 Care home staff giving medicines to residents

without their knowledge (covert administration)

Health and social care practitioners

• No covert if the resident has capacity to make decisions about their treatment and care

• Covert administration� In context of existing legal and good practice frameworks to protect both the resident and CH staff

• Process must include:• Process must include:– Assessing mental capacity,

– Holding a best interest meeting involving CH staff, prescriber, pharmacist and family or advocate

– Recording the reasons for presuming mental incapacity and plan

– Planning how medicines will be administered without resident knowing

– Regularly reviewing whether covert administration is still needed.

• Commissioners and providers to establish wider policy several health and social care organisations

Pharmacist’s role• Develop process and policy

• Capacity can fluctuate, can medication wait until resolved

• Explore if genuine reason for non adherence

• Holistic and objective review of medicines to determine that they will – prevent deterioration of physical or mental health

– maintain physical or mental health – maintain physical or mental health

– save life

• Combine evidence, with expert experience, patient circumstances, experience and values

• Regular medicines that are only needed prn can disguise as refusals e.g. laxatives!

• After long periods of non adherence, gradually re introduce medicines at low dose if need be

• Advise on best formulation, stability and administration methods

NHS Scotland Polypharmacy Guidance 2012

• The GP should write a statement clearly

outlining medication to be given “covertly”, &

• This must be kept in the service users care

plan, together with an explanation of the plan, together with an explanation of the

rationale for this action.

http://www.central.knowledge.scot.nhs.uk/upload/Polypharmacy%20full%20guidance%20v2.pdf

Case Scenario

Mr A

• Dementia, hx BPSD, wandering at night

• Sleeps all day and awake at night

• Nurses give his medicines in a cup but he wants to look through so he can take the Nitrazepam 5mg outlook through so he can take the Nitrazepam 5mg out

• He doesn’t want to take it

• Nurses not too pleased because if he doesn’t take it, he is awake all night, walking up and down, disturbing everyone and banging on exit doors

Nurse asks if they can give it covertly?

Covert or not?

Key points

• Assume patient has capacity to give consent unless there is evidence to suggest otherwise.

• Capacity is not an “all or none situation and people may have capacity for some decisions and not others

• Dementia doesn’t always mean lack of capacity

• The fact that a patient is supported physically to take their medicines does not mean they haven’t got mental capacity. medicines does not mean they haven’t got mental capacity.

• It cannot be assumed that a patient lacks capacity just because of their age, conditions, disability, behaviour or because they make a decision you disagree with

• Family views cannot override patients in isolation

• Intentional non adherence is usually to do with patient’s fears, values and experience of medicines� try to address!

Thank you