The NHS is under pressure as a result of an increasing and aging population, with people living longer and with complex multi-morbidities. Supporting people with long term conditions to help them manage their own health is likely to result in improved clinical outcomes, lower rates of hospitalisation and less need for emergency care (NHS Five Year Forward View, 2014). Optimising medicines ensures people obtain the best possible outcomes from their medicines, and supports the management of long term conditions, multimorbidities and polypharmacy (NICE Guideline NG5: Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes, 2015).
The Clinical Pharmacy workstream of the Enhanced Health in Care Homes Vanguard in Nottingham City therefore focused on conducting pharmacist-led level 3 clinical medication reviews for patients living in care homes. The methodology was to take a person-centred approach to medicines optimisation by:
A solution was required which would enable the Care Home Pharmacist team to demonstrate the clinical and financial value of their optimisation interventions, and their impact on individual patients, to support the evaluation of the Vanguard programme against its two key aims of optimising prescribing and reducing non-elective hospital admissions. Whilst the benefit of using pharmacists' clinical skills in medicines optimisation is widely supported (NHS England: Clinical Pharmacists in General Practice, 2016 and NHS England: Medicines Optimisation in Care Homes, 2018), there is no nationally recognised tool to support the assessment and evaluation of the interventions made. The aim of the project was therefore to develop a method of assessing and evaluating the impact of medicines optimisation interventions, by producing a scoring tool that was credible and simple to use, that attributed a financial value to each clinical pharmacy intervention, and that could be used in any setting where pharmacists conduct clinical medication reviews.
The Care Home Pharmacists in Nottingham City have developed COMPAS (Clinical Optimisation of Medicines - a Person-centred Assessment System). Other organisations have developed tools for assessing clinical pharmacy interventions, mainly in terms of cost savings from avoiding hospital admission. However COMPAS not only looks at the financial impact of avoiding hospital admissions, but adds another dimension by taking a person-centred approach to the evaluation which:
As one of the intended outcomes of the Vanguard was to reduce non-elective hospital admissions, a decision was made to develop a method of assessing interventions in terms of their likelihood of preventing a hospital admission. Research identified that a number of organisations have adapted the Hospital Avoidance Scale within the RiO healthcare management system, to assess the impact of clinical pharmacy interventions on hospital admission (acknowledgement to the work carried out by NHS South West London, Croydon Borough, which was used as a basis for the initial work in Nottingham City). A matrix of interventions was produced, which were categorised by type. Each intervention was reviewed by the Care Home Pharmacist team and agreement reached as to the most appropriate Hospital Admissions Avoidance Score (HAAS) that should be allocated. The matrix was developed and tested during the Vanguard programme using the significant number of actual interventions made by the Care Home Pharmacists.
The Care Home Pharmacists recognised the value in adding a further qualitative assessment to the scoring system as it was felt that by assessing only on hospital avoidance there was a risk of underestimating the significance of some interventions to the patient, for example on quality of life. A decision was therefore taken to further develop the scoring tool by adding an assessment of the Clinical Impact (CI) of each intervention to the patient, which helps to demonstrate the provision of person-centred care. COMPAS therefore consists of a comprehensive matrix of interventions, each with a HAAS and CI score, which is referred to whenever interventions are assessed to ensure a consistent approach by the team, and to which a financial assessment is applied.
It is recognised that there is an element of subjectivity in assessing interventions in this way, however this was mitigated as far as possible through peer review by the Medicines Management Pharmacist team in Nottingham City, and through additional validation by a Consultant Geriatrician at Queens Medical Centre, Nottingham and the medical consultant engaged by the independent evaluator of the Vanguard. The benefit of COMPAS is in its ability to demonstrate the impact and value of the work undertaken by clinical pharmacists.
Further work is being undertaken to explore the potential use of COMPAS more widely across Greater Nottingham as it is recognised that it has a benefit beyond medicines optimisation in the care home setting. It may also have a use in demonstrating the impact and value of quality and safety projects.
The COMPAS scoring tool:
1. HAAS rating - a person-centred qualitative assessment of the potential impact of the intervention which assigns a value of likelihood according to the prospect of that intervention preventing a hospital admission. The intervention is also categorised by type. The HAAS rating is influenced by the type of intervention, the medication involved and any patient-specific factors. Three values:
i) Level 1 - No likelihood of preventing a hospital admission
ii) Level 2 - Possible prevention of a hospital admission
iii) Level 3 - Likely prevention of a hospital admission
The HAAS rating results in the allocation of a financial value (described in 3. below).
2. CI rating – a person-centred qualitative assessment of the clinical impact to the patient, ensuring that the significance of an intervention is not underestimated by basing it on the HAAS alone. The ratings for HAAS and CI are independent of each other, so an intervention rated as HAAS Level 1 does not automatically rate as low for clinical impact. Three categories:
i) Low
ii) Medium
iii) High
The CI rating is not allocated a financial value.
3. A two-part financial assessment:
i) a value based on the HAAS. The local tariff for an average length of
hospital stay for an older person presenting at A&E is defined as the 'cost
avoidance figure' and is attributed to each potentially saved hospital
admission. This figure is therefore assigned to each intervention rated as
HAAS Level 3.
The 'possible' nature of interventions rated as HAAS Level 2 is also attributed a value and each HAAS Level 2 is assigned a value range:
'Minimum' – 5% of the cost avoidance figure per HAAS Level 2
'Medium' – 10% of the cost avoidance figure per HAAS Level 2
'Maximum' – 20% of the cost avoidance figure per HAAS Level 2
(Further information on the rationale used is available in the accompanying document 'COMPAS Scoring System').
Interventions rated as HAAS Level 1 by definition have 'no likelihood' of preventing a hospital admission and are therefore not attributed a value.
ii) the value of any savings or additional costs resulting from: de-prescribing;
initiating medicines to address unmet need; or changing medications,
formulations or dose regimen. (Costs associated with monitoring requests
and costs/savings associated with dispensing fees are excluded for
simplification).
In summary, although a number of organisations have produced assessment tools, COMPAS, developed in Nottingham City CCG, is different because it takes a person-centred approach to the evaluation by considering the patient's individual needs and preferences, as well as the qualitative impact on their health, wellbeing and quality of life.
The patient:
Although the patient benefits from medicines optimisation interventions whether they are assessed using COMPAS or not, its use:
The results and outputs from using COMPAS to support medicines optimisation in care homes has resulted in two of the pharmacists being recruited into permanent Care Home Pharmacist roles in order that patients in the wider Greater Nottingham area can benefit.
The team and wider healthcare system:
The team and wider healthcare system benefits from the use of COMPAS in assessing and capturing the impact of medicines optimisation strategies as:
Patient:
COMPAS was used to assess clinical pharmacy interventions over the 12 month period July 2017 to June 2018:
Financial:
For the same period COMPAS demonstrated cost avoidance savings* of:
plus:
which represents:
*Based on the cost avoidance figure at the time of the Vanguard, which was £2,492.
