Our work is a commissioned integrated service between health and social care providers - BEDOC Complex Care Team and Bedford Borough Council.
There is a considerable amount of focus on medication in care homes which has led to the appointment of NHS England funded care home pharmacists and technicians across the country. Over recent years many articles have ben published in the Pharmaceutical Journal and others, show-casing the fantastic work that is being delivered by reducing polypharmacy and carrying out reviews as well as initiatives to optimise medication management.
The work cited by Wigan Clinical Commissioning Group (WCCG) (1) highlighted collaboration between the medicines management team within WCCG and the local authority to support homes and improve standards of care in medicines management, in addition to the clinical input of medication reviews. As commissioners CCGs are not in a position to provide continued structured support to maintain the desired high standards in medicines management.
Our work aims to support Bedford Borough care providers through an annual and pro-active monitoring process to achieve and maintain delivery of safe and high quality care to service users. The process aims to identify risks of a decline in service at an early stage before potentially resulting in safeguarding concerns or closure of a service. Our work covers all care providers commissioned by Bedford Borough Council including not just residential and nursing homes for older people but also learning disability residential and nursing homes, domiciliary care service providers and supported living services.
In addition to annual monitoring the team responds pro-actively to safeguarding concerns around medicines management when referrals are made by Bedford Borough Council. Our input provides expertise to identify root causes and support homes to make necessary changes to mitigate further risks.
The team also supports the work of Bedfordshire Clinical Commissioning Group by promoting the appropriate use and implementation of homely remedies to reduce waste of "when required" medication. Advice is given on stock management when there is evidence of excess stored medication to reduce waste and costs to the NHS. Furthermore there is the potential to support the safe implementation of "self-care" in care homes in the future.
At the NCAS (National Children's & Adult Services) conference in October 2017 ADASS (Association of Directors of Adult Social Services) Past President, Ray James, advocated the need for Councils to be "more fixated on quality" and highlighted the importance of monitoring for failing providers.
Through structured collaborative working we aim to rise the quality of care delivered to our service users in all aspects of care and to maintain these high standards. Medicines management is one small part of the care needs which providers deliver and we aim to remove the "silo" approach to support by integrating health and social care through close joint working.
The Complex Care Team has evolved over the last nine years, integrating work with both pharmacists and nurses to pro-actively support care homes, initially in the Bedford locality. The team has a website which offers resources for our providers. http://www.complexcarebedoc.co.uk.
The Complex Care Team was initiated as a pilot funded by Bedfordshire CCG with the aim of reducing GP visits to care homes to treat minor ailments and to reduce inappropriate hospital admissions. Pharmacists carried out medication reviews and medicines reconciliation following transfer of care and nurses provided a clinical assessment to triage appropriate support on a daily basis, five days a week. Bedford Borough Council also provided an element of funding to the team to support contract monitoring officers in their monitoring schedule.
Through data collection and audit the service provision then developed into two divisions to most effectively meet the needs of the local targeted population:
For the purposes of this award, BEDOC Complex Care Team are submitting their work with Bedford Borough Council only, as this represents true integrated working across health and social care providers and has the potential to form a structure for the nationally funded NHS England Care Home pharmacists and technicians.
Bedford Borough Council initially commissioned 15 hours a week for pharmacist input and, finding the effectiveness of this input increasingly valuable, developed a specific service design for a structured contract to expand the role. This was achieved through evaluating feedback from partners and additional investment in the Care Standards team workforce. Subsequently a new contract was implemented in April 2018 with a Service Level Agreement for 30 hours per week of pharmacist support.
The Complex Care Team has been part of a new monitoring system that Bedford Borough piloted. The Provider Assessment & Marketing System (PAMMS) is a web based monitoring tool that is designed to support data gathering, workflow management and analytical information, bring Bedford Borough in line with other ADASS Eastern region local authorities. The tool enables a consistent approach to monitoring provider services, and the pharmacists are commissioned to provide a structured report on the medicines management provision delivered by the individual care providers, to the Monitoring Officers, for them to integrate into the web based programme.
Following data input by the BBC Monitoring Officers, the PAMMS tool provides an overall rating for the provider services mirroring the approach of the regulator CQC Key Lines of Enquiry (KLOE's). It also identifies actions that the provider needs to work on to improve the areas of care highlighted as "requires improvement".
A joint follow up visit then reviews the action plans with the provider which will include the pharmacist if medicines concerns or risks have been identified.
In addition to the PAMMS monitoring input, the pharmacists may be asked to support providers and review their procedures in line with mandatory standards and best practice guidance. This may be where risks have been identified through Safeguarding investigations or through quality assurance referrals. Links can be made to the BCCG commissioned service or CCG Care home pharmacist, which provides a referral route to manage the direct healthcare needs of consenting service users.
As this is a new contract we do not have current data to demonstrate its effectiveness but we believe that we now have a model which can be audited and may identify tends and highlight risks at an early stage. The evolution of the service has resulted in a consistent monitoring process using the expertise of healthcare professionals. This supports Bedford borough Council in meeting their duties under the Care Act 2014, which sets out the law around market development in adult social care. It enshrines in legislation duties and responsibilities for market-related issues for the Department of Health, CQC and Local authorities.
Section 5 within the Act sets out the duties placed on local authorities to facilitate a diverse, sustainable and high quality market for the whole population, including those who pay for their own care and to promote efficient and effective operation of the adult care and support market as a whole. (2)
Through our recent collaborative work we have identified the importance of sustained commissioned support to maintain standards. We believe this is an innovative pro-active approach when compared to ad hoc unstructured support that has not previously addressed the holistic needs of our local care-for population.
We believe our integrated team now has a model which will build on the work begun in Wigan to support Local Authorities and which could potentially be adopted nationally. We have also recognised that we cannot exclude homes supporting people with learning disabilities and that domiciliary providers need enhanced support in medicines management. This is an agenda which we are now beginning to tackle.
The population of Bedford who utilise care provider services:
There are 13 care homes registered to provide nursing services in Bedford with 575 beds and 64 residential care homes without nursing providing 1004 beds.
1,268 service users receive Borough funded domiciliary care through 33 active agencies but it is not possible to estimate how many people in total are using domiciliary care services as many will be self-funding their care directly to providers.
These are vulnerable people who trust their providers to deliver appropriate and safe care. The management of medicines clearly carries a high risk of potential error. The CHUMS report provided a structured analysis of medication errors in care homes as one glimpse of the potential problems (3).
A systematic review of Carers' Medication Administration Errors in the Domiciliary setting by Parand A et al 2016 included 36 papers only two of which were English and cited a range of reasons for medication errors but mainly citing unpaid carers. (4). The true extent of the problems in this sector is largely unknown.
Through our structured work with Bedford Borough Council we can begin to identify trends and support providers to mitigate risks through an integrated approach. The domiciliary care setting is the biggest challenge due to the diversity of the providers an the complexities of managing lone workers.
When our work successfully delivers its aims, the risks of medication errors will potentially be reduced for these vulnerable service users.
In addition, many of the care homes cited by the media for poor care and abuse are Learning Disability homes. Following the Winterbourne scandal in 2012, NHS England produced a report to review the commissioning of the service for learning disabilities and autism. (5)
Capacity issues due to the high numbers of small residential settings, often with only between 5 and 10 service users, means that these registered homes are not supported by CCG care home pharmacists or technicians. As commissioning organisations this is also not within their remit. Our team will provide measurable support to raise standards of medicines management in these settings by highlighting issues which may increase risks of error.
Bedfordshire Clinical Commissioning Group (BCCG):
GPs sometimes report that care homes present them with extra demands in managing the needs of their service users. With the appointment of NHSE pharmacists and technicians it is hoped that these demands will be managed especially in the process of reviewing medication. In Bedford the capacity to cover 1576 service users is doubtful. BCCG also employs a pharmacist and technician to support care homes which as a commissioning organisation is delivering a service which should be supported by a commissioned provider.
The integrated work of the Complex Care Team and Bedford Borough Council focuses on holistic care, not on medicines reviews, and has the potential to reduce the peripheral demands on GPs triggered by poor medicines management and safety concerns. Our work has the capacity to identify medication risks at an early stage and whilst the remit is not to review medication, if any issue arises this can be highlighted to the medicines management team at BCCG or the GP.
During the monitoring visits the team are fully aware of the BCCG medicines formulary and the need to identify medication waste. A key element of the safe management of medication is stock control and the home can be advised to review the ordering processes to minimise waste. The management of "when required" medication identifies personalised protocols and the need for regular reviews to encourage the use of "homely remedies" where appropriate. This has the potential to support BCCG targets in managing drug budgets and the move towards self-care for appropriate medication.
Bedford Borough Council:
The Association of Directors Of Adult Services (ADASS) assert that "it is important not to rely only on single means of quality assurance but to be able to triangulate information from different sources to be able to evaluate effectiveness, both of partner organisation as well as the partnerships (ADASS 2011). (6).
A Local Authority has lead responsibility for safeguarding in its area. Safeguarding issues are more likely to arise in service that offer poor quality of care. Commissioners should therefore take an active interest in the quality of all care service provision in their area, including the integration of health and social care. Bedford Borough Council recognises that their Monitoring Officers have extensive expertise of care provision but they do not have the specialist clinical expertise to identify potential risks in medicines management. By implementing a structured and integrated health and social care approach, the monitoring process becomes robust, holistic and measurable.
BBC Monitoring Officers can confidently leave the medication issues to the Complex Care Team pharmacists allowing them time to focus on the other domains of care and reducing the overall time taken to carry out the monitoring visits. This potentially means that efficiency is improved and there is more resource to carry out a greater number of monitoring visits annually.
With the utilisation of the PAMMS tool and the Complex Care Team, BBC can pro-actively support its providers to improve their management of medicines through the constructive feedback they receive.
The structured integration model currently being used has only been commissioned since April 2018 and within the first quarter 15 full PAMMS monitoring assessments have been completed. Consequently there is limited meaningful data to indicate success in a measured way. The PAMMS on line tool is new to Bedford Borough Council and the understanding of the recording matrix is evolving. Having completed the first quarter of the service the initial teething problems have largely been resolved.
The overall grading rating outcome of the PAMMS tool uses complex algorithm processes to integrate standards of care. Medicines management issues are embedded into several of the assessment domains.
The history of integrated working between BBC and the Complex Care Team has led to a monitoring approach which we feel will provide robust and meaningful information. By identifying trends it is possible to ensure that identified vulnerabilities are followed up for risk mitigation, and that perceived or actual information of incidents are managed in accordance with NHS information governance requirements.
The method of recording now enables reports to be produced and allows access to historic information to view provider progress.
We feel the main achievement for medicines management is that we now have a consistent and robust monitoring system which integrates with the holistic care of service users. We expect that the ratings for our care providers may initially fall as we identify quality issues but through on-going support we anticipate sustainable improvements.
The ultimate outcome we aim for through our integrated work is to provide maintainable support to our care providers to keep our vulnerable service users safe across all care stings, in particular learning disabilities and domiciliary care which have historically received little support. We aim for our providers to achieve outstanding in their care provision by being there for them.
