NPC Conference Medication review workshop 2

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NPC ConferenceMedication review workshop 2

• Lelly Oboh(Consultant pharmacist )
• Nina Barnett (Consultant pharmacist )
• Bunis Packham (Nurse consultant)
• 1st July 2008

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This session will focus on how we can commission,
target and deliver medication review (m-r)
services to assist patients get the best from
their medicines
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Overview of each session

• Presentation (max 10-15mins)
• Introduction
• Description of your case study
• Use the slides to highlight the key issues when
  developing and evaluating the service
• Group work discussing pros cons (30mins)
• Feedback and new ideas for m-r services that they
  may want to take forward (15mins)

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Case study 1 Medication review as part of a
community based anticoagulation service

• Nurse consultant carries out review of all
  medication and assess drug interaction and the
  need for some of the other medication while on
  anticoagulants as part of initiating and
  monitoring therapy
• Considers the reason for anticoagulation
• Asseses clinical and social circumstances
• Undertakes risk v benefit analysis
• Reviews medication incl polypharmacy issues
• Discontinue antiplatelets or PPIs inhibitors
• Develops detailed planned individualised strategy
  to monitor the treatment
• Prevention and detection of adverse events
• Patient/carers education
• Involves patients in the decision making process
  and encourages them to report any changes in
  medication or medical condition to the
  anticoagulation clinic
• Informs patients about the risks and benefit of
  treatment offered and any alternatives offered in
  order for patients to make a fully informed
  decision.
• Discusses drug interactions at the initial visit
  and reinforces the message in the patients hand
  held record (contains all the information about
  their anticoagulant monitoring)

• Consultant nurse
• Follow up clinics are to monitor the INR levels
  and to monitor drug interactions with alterations
  to other medication
• Carries out a range of audits to evaluate service
  e.g.
• Patient satisfaction survey of Nurse Led
  service
• New patient perspective of anticoagulation
  service
• Perception of stakeholders of the service-
  clinicians and patients
• DNA audits

Patients presenting at anticoagulation
clinic Referrals are from clinicians both from
primary and secondary care Patients are referred
to assess suitability/or patients already on
anticoagulants
Medication Review process
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Case Study 2 Medication review as part of
holistic approach to reviewing medicines in
intermediate care continuing care patients in a
care home

• Pharmacist carries out full clinical medication
  assessment as part of a multidisciplinary team
  (consultant, nurse, pharmacist and other
  health/social care professionals)
• for each med
• ? when why it was started,assessed for
  continuing need, in view of the patients
  physical, mental, emotional and social situation.
  
• ? Drugs indicated but not prescribed e.g. for
  prevention of osteoporosis
• Patient or carers give input as appropriate
• Simple pro-forma used to ensure that all the
  patients medical needs (incl. medication) are
  addressed

• Long-term, continuing care (CC) patients
• According to need
• On admission
• At 3 6 mths
• Annual review if the patient is medically stable

• Pharmacist role includes
• Following up recommendations from previous care
  setting
• Providing ongoing support via ward rounds and
  multidisciplinary team meetings
• Liaison with next care setting to optimise
  continuity of pharmaceutical care
• Prescribes (within own scope of practice) to
  optimize drug regimens, usually in the context of
  the multidisciplinary team

• Pharmacist
• Carries out combination of 'types' of m/r
  tailored to individual patient need at the time.
  1st review usually within 3 days of admission.
• All reviews focus on ensuring that patient
  receives medicine appropriate to their needs in
  both the current and take account of next care
  setting (usually home).
• Undertakes m-r from multiple perspectives by
  assessing
• ? Clinical need for medication (incl. drugs
  indicated but not prescribed),
• ? Physical ability to take and use medicines
• ? Social situation around medicines taking,
  particularly after discharge.
• Facilitates a self administration of medicines to
  ensure that patients can use and take medication
  prior to transfer out of the intermediate care
  setting
• Liaises with wide range of health and social care
  professionals in 10 20 care e.g. Harrow
  Healthcare And Rehabilitation Team (HART),
  patients community pharmacist to optimize
  continuity of pharmaceutical care.

• Intermediate care patients (6 weeks
  rehabilitation)
• On admission
• Twice weekly for the first two week then weekly
• 3 days before discharge

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Case study 3 M-R service to care homes
Medication review pathway
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Deciding what is important

• What problem is the the m-r service is trying to
  solve?
• Will it improve access and patient convenience
• Will it prevent hospital admissions or allow
  patients to remain in the community
• Will it improve mortality, morbidity or promote
  independence
• How does it fit in with local/national priorities
  or must dos?
• How does it fit in the wider multidisciplinary
  approach to improve patient care?

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Deciding the scope of the service

• What type of review is proposed
• How did you decide your target patients i.e who
  will benefit most
• High risk patients e.g. 6 medicines at level 3
  or housebound patients
• Specific groups e.g. CHD, diabetics, dossette box
  patients, asthma, Mental health etc
• How did you decide the professional with the most
  appropriate level of expertise

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Thinking about the practicalities

• Who needs to know about the service i.e.
  stakeholders?
• How will this information be communicated to
  them?
• Multidisciplinary working and developing
  partnerships
• Where will the m-r service happen?
• Who will carry out?
• What training will they need?
• How will patients be selected for review- From
  practice or pharmacy records, at over 75 checks?
• How will they be referred to the pharmacist?
• Did you agree a pathway, tools, templates, access
  to information and sharing?
• How will review be recorded?
• Who will implement the recommendations and
  monitor?

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Ensuring that the service is safe and good value
for money

• Training, maintaining competency and supervision
• Performance management and service level
  agreements
• Auditing the process and outcomes
• Patient feedback and satisfaction
• Healthcare professional feedback
• Outcome data
• Activity e.g number of referrals, DNAs
• Proxy measures e.g. meeting QoF targets
• Prescribing data

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Funding streams

• Pharmacy contract- local enhanced service
• GMS contract local enhanced service
• PCT prescribing budget
• PBC commissioners
• Health and social care initiatives
• Medicines management team
• Pharmaceutical industry
• Care homes

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Group work (capture on flip chart)

• In three groups (what do you think?)
• Primary care (GP practice, patients homes,
  community pharmacy) 
• Care home/intermediate care settings
• Hospital settings

Discuss the pros and cons of your own service