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Workshop 2: Benchmarking solutions showcase
- 1. Benchmarking solutions showcase 13 June 2013
- 2. 1. London Older Peoples Service Development Programme 2. My Medication Passport 3. Optimize Adherence Service Current solutions
- 3. 1. London Older Peoples Service Development Programme
- 4. London Older Peoples Service Development Programme, Lelly Oboh, April 2003 Aim • to promote independence among older people, through the delivery of person- centered, coordinated services LOPSDP medicines management pilot
- 5. LOPSDP medicines management pilot Patient Case Selection Social services staff, Nurses, Occupational therapists, etc Initiate Single Assessment Process (SAP) 4 questions about medicines Social services or health staff Continued Care Case manager or care coordinator (health or social service staff) The Medicines Management Project In-depth Medication Assessment & Pharmaceutical Care Plan Specialist Pharmacist Provide Pharmaceutical Care Package Community Pharmacist Nurse GP Carer London Older People Program Referral Pathway Adapted from: Lelly Oboh, LOPSDP, The ‘Medicines Management’ Project, (January to July 2003)
- 6. Single Assessment Process (SAP) 4 questions about medicines Area of Concern Single Assessment Process (SAP) Questions Access issues Q1. I need help getting a regular supply of my medicines. Compliance issues Q2. Sometimes I do not take my medicines the way that the doctor wants. Day to day medicines management issues Q3. There are some medicines that I cannot get out of their containers. Clinical issues Q4. Realistically, I think some of the medicines that I take could work better.
- 7. In depth medicines assessment by specialist pharmacist Area of Concern Example Questions Access issues Has you ever run out of medication? Compliance issues Do you need any help taking medication? Do you use a compliance aid e.g. blister pack? Day to day medicines management issues Can you use your inhaler properly? Can you open and remove medicines from a blister pack? Clinical issues Pharmacist assesses the safety and appropriateness of medication.
- 8. Care Plan delivered and monitored by community pharmacist Patients name: DOB: Assessed by Date: Tel: PHARMACEUTICAL NEEDS IDENTIFIED PLAN ANTICIPATED OUTCOMES AND ACTION Access issues e.g. repeat prescription collection Patient does not run out of medicines Compliance and day-to-day medicines management issues e.g. medication provided in easy-open bottles Patient able to take medicines Clinical issues (Identify the problem or risk involving medication, including failure to prescribe for an condition) e.g. liaise with GP / diabetes specialist nurse for blood glucose monitoring Good blood glucose control and medication used to get maximum benefit for the patient
- 9. LOPSDP pilot - benefits • number of hospital and GP attendances • waiting times & speeded service delivery • Developed joint training & multi-skilling • Improved information & improved processes • Empowered front-line staff LOPSDP pilot - benefits
- 10. LOPSDP medicines management pilot Patient Case Selection Social services staff, Nurses, Occupational therapists, etc Initiate Single Assessment Process (SAP) 4 questions about medicines Social services or health staff Continued Care Case manager or care coordinator (health or social service staff) The Medicines Management Project In-depth Medication Assessment & Pharmaceutical Care Plan Specialist Pharmacist Provide Pharmaceutical Care Package Community Pharmacist Nurse GP Carer London Older People Program Referral Pathway Adapted from: Lelly Oboh, LOPSDP, The ‘Medicines Management’ Project, (January to July 2003)
- 11. LOPSDP pilot - considerations • Sounds complicated: multiple professions and referrals • Role of care co-ordinator vital • Communication pathways to be established • Training staff to understand the 4 trigger questions and carry out reviews • Time constraints • Backup plans for IT failure / lack of trained staff LOPSDP pilot - considerations
- 12. 2. My Medication Passport
- 14. Imperial College - My Medication Passport • Basic rules about medicines • Contact details - Patient, GP and community pharmacist • List of allergies / medicines that can’t be taken • List of medication aids • Medicines reminder chart • List of changes to medication and reasons Imperial College - My Medication Passport
- 15. Imperial College - My Medication Passport Benefits • Concise list of patients’ medication • Booklet or App (available on phone, computer) • medication-related problems during transfer of care e.g. allergies, interactions • Adapt to include other information e.g. contacts of diabetes specialist nurse, carer etc. Imperial College - My Medication Passport
- 16. Imperial College - My Medication Passport Considerations • Too many pieces of paper / information e.g. warfarin booklet, steroid card, insulin passport. – Can we place them all together? • Will patients / healthcare staff use the passport? • Cost of booklets and implementation Imperial College - My Medication Passport
- 17. 3. Optimize Adherence Service
- 18. Optimize - A Medicines Adherence Solution provided by Green Light Pharmacy in it’s Stepney branch commissioned byTower Hamlets PCT in 2012 & now by NHS England
- 19. There is no impending pharmaceutical discovery, surgical innovation or governmental policy change with greater potential for improving the health of patients and efficiency of the health care system, than simply increasing the percentage of treatment plans that patients (are able to) carry out as prescribed [Align Map www.alignmap.com ]
- 20. “Drugs don’t work in patients who don’t take them” C. Everett Koop M.D – Surgeon General USA 1982-89 It is estimated that 50% of all prescribed medication is not used by patients as intended by the prescriber [ Sackett D.L., Snow J.C. “The Magnitude of Compliance & Non-Compliance” In: Haynes R.B. et al (Eds) “Compliance in Health Care” Baltimore, John Hopkins University Press 1979; Nov 22] It has been estimated that between 20 and 50% of patients are not adherent to their medication regimeKripalani S, Yao X, Haynes RB. Interventions to Enhance medication Adherence in Chronic Medical Conditions: A systemic Review. Archives of Internal medicine 2007; 167:540-550 Improving medicine taking may have a far greater impact on clinical outcomes than an improvement in treatments Haynes R.B., Ackloo E., Sahota N., McDonald H., Yao X. “Interventions for Enhancing Medication Adherence” Cochrane Database System Review 2008; (CD0000011) 33-69% of all medicine related hospital admissions are due to poor medication adherenceOsterberg & Blaschke. New England Journal of Medicine 2005 Vol 353 Only 4 to 21% of patients are receiving the optimum benefit from their medicines Garfield S, Barber N, Walley P, Willson A, Eliasson L. Quality of Medication Use in Primary Care - Mapping the Problems, Working to a Solution: A Systemic Review of the Literature. BMC Medicine 2009; 7:50
- 21. • To support independent living • To improve patient adherence with therapy by – Improving understanding – Identifying practical problems – Supporting the carer • To reduce wastage and thus make cost savings by decreasing the local prescribing budget • To help people manage their medicines safely & appropriately • To decrease Preventable Medication Related Hospital Admissions and thus make cost savings to the CCG’s Hospital Admissions budget
- 22. The service focuses on improving, supporting & monitoring adherence (how people take their meds) not simply on the provision of compliance devices (ie not just a blister pack, other solutions as well)
- 25. Optimize addresses: Unintentional non compliance – Access (eg over / under script request) – Physical issues (using inhalers, reading English) – Adherence solutions (Blister Packs , Reminder Charts, prompts eg phone call, text, phone aps ) Intentional non- compliance – Cognitive support – Meds Education Plan – Patient held meds record - their “Medication Passport” – Condition Education Plan – Adherence Record – Reward Plan – Relapse Plan
- 26. Optimize:A MedicinesAdherence Solution Referral Adherence Assessment by AccreditedCP Support Plan & Report (SPAR), carried out by patient’s usual, localCP. (Compliance aids; cognitive support; use of MAR sheets; reminders/prompts) Discharge from service, but with on-going Support Plan Review (initially at 3 months, t hen every 6 months) Evaluation of Referral by Accredited Community Pharmacist (CP) Patient referred to other health & social care services and/or contacted by accredited pharmacist to discuss the reason for the referral and possible solutions. Inappropriate Referral Appropriate Referral Adherence Evaluation by Accredited CP (usually as a domiciliary visit) Adherence MUR Plus by AccreditedCP Support Plan Communicated to the patient, as user friendly (patient held) Medicines Passport Patient carries on in the service Annual Report & Evaluation of Service to Commissioner by Service Provider
- 27. Unused Meds, collected from just ONE patient, prior to joining Optimize service
- 28. Evaluation of Data Due end July 2013 (from 1st six months of service) Evaluation will be supported by UCL
Editor's Notes
- Systemwide Improvement of Services for Older People http://www.ihi.org/knowledge/Pages/ImprovementStories/SystemwideImprovementOfServicesForOlderPeople.aspx The aim of the two-year programme was to promote independence in the London community of older people, through the delivery of person-centered, coordinated services.The specific objectives were: To identify vulnerable older people at risk in the community, using a case finding or case management approach To initiate the single assessment process (a new government led multi-agency, multidisciplinary, whole person assessment system to reduce duplication and speed processes), wherever the person enters the system To deliver coordinated services in the community To gather systematically the views of older people and caregiverIn the next few slides I will discuss the medicines-related programme.
- All health and social care professionals can carry out the single assessment process (SAP). In this there are 4 trigger questions about medication. I will explain these questions in the next slide. If the answer to any of the questions is yes, the patient is referred to a specialist pharmacist for a detailed medication review. The specialist pharmacist develops a pharmaceutical care plan which is then sent to the patient’s local community pharmacist who then delivers and monitors the care plan. They may need to liaise with the patient’s GP, nurse or carer and with the care co-ordinator.If the patient does require any health or social care then their case is sent to the care co-ordinator who then co-ordinates all the communication and health and social care for that patient.
- These four trigger questions can be asked by anybody in health or social care. They can even be asked in hospital during an inpatient stay.The questions address the issue of accessing medicines, adherence or compliance, day to day issues with taking medicines and clinical issues.If the answer to any of the 4 questions is yes, the patient is referred to a specialist pharmacist for a review.
- Upon receipt of a referral, the specialist pharmacist requests obtain a summary of patient’s medication and health problems from the GP.The specialist pharmacist carries out a detailed review of the patients medicines.The key themes of this review are the same as the 4 trigger questions but there are detailed questions about each. In the assessment, the top three are similar to MUR but more detailed. The fourth, medication review, requires specialist clinical knowledge / training.Questions covered in Access IssuesGetting repeat prescriptions / Delivering medication to patientHas patient ever run out of medication?Compliance issuesDoes the patient need any help with taking medication?Does the patient currently have a compliance aid?Do you know/understand how to take the medicines?Day to day medication management issuesAny problems with swallowing tablets, reading labels, mobility, manual dexterityCan they instil eye drops or use inhalers properly?Clinical medication reviewConsider appropriateness of each medication (indication, dose, ADR, drug interaction, monitoring)Consider patient’s medical conditions (untreated condition, drug use without indication)
- The role of the community pharmacist is crucial here.The pharmacist will not only be delivering the care plan in a practical way but also monitoring this plan. In the programme follow-up was after 6 months but it can be more frequently.Monitoring and review are very important because they give patients and professionals a chance to understand what is working well and take steps to improve other aspects. This is especially important if the patient’s condition has changed since the initial review with the specialist pharmacist.
- This project has already shown some positive results with reduced hospital and GP attendances. The improved communication pathways have resulted in better flow of information between various agencies / professionals and therefore resulted in faster service for patients. Staff working directly with patients are able to help the patients immediately by making referrals rather than simply signposting patients to appropriate services.
- A quick look at the programme again. There are several communication streams and multiple health professionals involved in the scheme.
- The programmes sounds and looks very complication with multiple professionals and referral or communication pathways. It is important to get the communication pathways clear to prevent failure. Forms may be posted, faxed, emailed between agencies, but there should be feedback/acknowledgement mechanism in place too.The role of the care co-ordinator is vital as they are co-ordinating both the health and social care for the patient.Staff training is required to ensure these new roles can be fulfilled. So staff should be trained on how to ask the 4 trigger questions and refer.Pharmacists will need to be trained to develop care plans and packages. It is also important to understand the time required to performs these additional tasks and this will have resource implications. Such a system relies on complex communication and trained staff and most importantly the care co-ordinator. There should be plans in place for continued safe service during these systems failures.
- Communication of medication changes across interfaces is a well recognised issue within the NHS. Whenever a patient transfers care settings there is a risk that information about their medicines is not transferred, or inaccurately transferred.My Medication Passport is a written record of a patient's medicines. My Medication Passport was launched on 17 April 2013 The medication passport is designed to help the patient and anyone involved in the patient’s care to understand their current medication and changes to it and what the cannot take.It should be shown to the GP, pharmacist, dentist or any other healthcare professional involved in provision of care. It should be presented at outpatient appointments and at A&E attendances.The passport has been given to over 5000 patients across Imperial College Healthcare NHS Trust with excellent feedback. The plan is now to make the passport available across the wider area of North West London and then potentially further afield.
- It is designed to improve communication between patients, carers and healthcare professionals and maintain a record of changes made to the patient's medication. Features of the medication passport include:Relevant information about the patient and his/her GPList of medicines that the patient cannot take and the reasons whyCompliance aids in useList of the patient's current medicines List of changes to medicinesWhat are the aims?The passport aims are to help patients/carers have a complete record of their medicines as well as an understanding of the reasons for any changes being made to their medicines. It's designed to empower patients/carers to take control of their medication and help seamless transfer of medication information across healthcare interfaces.Passports are available in two formats:As a paper based booklet As an app for iPhone or Android phones
- It lists patient’s medication as well as medication that the patient cannot take. Recent changes to medication are also documented so health professionals can get a brief medication history.Available as a booklet or App – it is useful for patients of all ages, especially those who have and know how to use Smart Phones. Information is instantly accessible.Because all medication is listed clearly, it avoids problems during transfer e.g. when patients go to hospitals or see another health professionals. Health professionals can check the patient’s medication list and prescribe new medicines that do not interact with the current medicines. During outpatient clinic appointments at the hospital, this is very important as the Drs don’t always have a list of the patient’s regular medication when they see the patient.This booklet could also be adapted to include other information that is relevant to the patient e.g. the contact name and number of their specialist nurse, carers etc. and this will allow better communication between professionals without having to go to the GP each time.
- A booklet just for medicines will increase the amount of medicines-related documents/paperwork that patients have to carry with them. Patients on warfarin have yellow anti-coagulation booklets, those on insulin have the insulin passport.It may be worth if we could have a booklet that had space to add these other documents.Will patients carry their booklets / passports. The App is a good idea and can be used if people have smart phones. We could wait to see what the response is from the Imperial project.Will healthcare staff use the booklet. At the moment, staff write in other patient records (e.g. medical notes) but on patient-held information. Staff training and commitment are also required. Also need to include hospital staff who may prescribe/change medication. They should be documenting their actions in the booklet too.There is a cost associated with these and the scheme should only be commissioned if there is significant commitment from all parties to use the booklet at all times.