Winner - Improving Health and Minimising Risk to Care Home Patients (2018)

East and North Herts CCG


East and North Hertfordshire have an elderly care home population of about 3,000. Many have complex health conditions requiring a daily average of 7-8 prescribed medicines, rising to ten in over 75-year-olds.

East and North Herts CCG introduced a multidisciplinary care home pharmacy team to improve the health and wellbeing of residents.
Evidenced risks associated with patient harm include:

  • staff with limited medicines management training, exposing residents to errors
  • adverse drug effects
  • increased hospital admissions

The team works to improve medicines optimisation and reduce medication errors, avoidable hospital admissions and medicines waste. Care home staff are supported to improve medicines management systems.

Dieticians support carers to increase their understanding of nutrition in the elderly, reducing the necessity for oral nutritional supplements (ONS).
Over three years the team has:

  • Achieved overall annual drug cost savings of almost £400,000
  • reviewed medications for 1,869 patients - 17,848 medicines
  • stopped 16% - 2,929 medicines
  • 1,099 of the medicines stopped had an increased the risk of falls. Of 159 anti-psychotic medicines reviewed, 28% were reduced or stopped.
  • replaced 65% of prescribed nutritional supplements with appropriate food, generating annual savings of £129,000.

How was the project established? / How is it currently being established?

(Please see full project pack for the business case for the initial project/)

What started as an NHSE ‘Vanguard’ project has now become business as usual.

Our newly developed Risk Stratification tool enables the best use of our pharmacy technicians’ time and skill-mix, by conducting medicines’ reviews for less complex/mild frailty patients, whilst focusing on where to prioritise our work and attentions.

The SystmOne (S1) review template allows clinical reviews to be completed faster and ensures all confidential information in one place.
Our project has paved the way for NHSE funding for more care home pharmacists and technicians to work across England to reduce unnecessary meds. (See attached BBC link)

The project has saved an estimated £790,000 in hospital admission costs (based on the RiO method of attributing the likelihood of a hospital admission, as a result of a medicine-related intervention). This recognises that cost savings result from reducing adverse effects of medication/avoidance of hospital admissions - rather than direct drugs costs)
We also supported 400 care home staff to identify malnutrition and enhance the nutritional content of food.

We have applied a Meds Observation tool (pharmacy technicians) in approximately half of the homes engaged with. Action plans were developed as a result of findings, improving medicines safety and staff understanding. The Meds Observation tool allows a more patient-centric approach to optimising problematic polypharmacy and identifying poor compliance and non-adherence issues.

Who are the main beneficiaries of the project? How would they benefit?

Residents have reported high levels of satisfaction with our services and facilitated discussion with their relatives. They also report a reduction in drowsiness/sleepiness, reduced pill burden, decreased risk of falls and a better understanding of their drugs (e.g. importance of bone health, fortified food and good sleep hygiene.

Care home managers reported increased levels of job satisfaction among carers, while GPs valued the facilitation of deprescribing, in conjunction with pharmacists’ expert knowledge.

Care home staff welcomed the teamwork, expert advice and support - especially pharmacy technician support to review ordering and medicines administration processes.

GP Dr Shona Hyde said "When a new patient enters a care home it takes time to get to know them and their medications. The opportunity to spend protected time focussing on individual patients is very beneficial and the pharmacist’s input extremely useful."

Letchworth GP Dr Caroline Whelan said lots of new processes have been introduced at a local home and her surgery. “We have reduced medicine burdens for many residents. One lady had her meds reduced from ten to two and thinks it’s the best thing ever.”
Geriatrician Dr Abdul Malik sat in on a medications review. He said: “This process of working closely with the GP, care home manager and pharmacist is so easy and understandable, both in terms of the resident and their medications and possible medication-related harms, and in education for the staff looking after them.”

Prescribers and care home staff valued the interventions and multidisciplinary discussions, reporting improvements in residents' wellbeing – e.g. reduced drowsiness, sleeping better and enjoying their food more.

What were the main outcomes and / or achievements of the project?

Following in-depth medication reviews, pharmacists' recommendations are actioned with the prescribing doctor and care home team via direct digital access to residents' clinical records. Since December 2015, 1,869 patients in 52 care homes have received medication reviews.

Out of the 17,848 medications that have been reviewed:

  • 16% were stopped
  • 37% could be linked to falls
  • 82% of suggested interventions were actioned.

The average direct drug savings were £210 per year, per patient.

An agreed set of data was captured working with care staff and the multidisciplinary team focussing on medicines optimisation recommendations, those accepted and those put under review. The percentage of accepted recommendations was recorded, along with savings from medicines stopped, interventions that reduced the anticholinergic burden and medicines stopped that may contribute to falls.

A comprehensive, visual dashboard was developed showing key outcomes.

Where an intervention was believed to prevent hospital admission, they were scored according to the 'RiO' system. Money saved from admissions was calculated using the tariff price for the age group, multiplied by the number of prevented admissions from pharmaceutical interventions.

Outcomes showed savings on medicines of £329,649, £1.05m in A&E attendances and £790,000 in hospital admissions.

Dieticians reviewed all residents taking ONS products; some were replaced with FoodFirst measures. They also delivered staff training on MUST calculations and fortification of food and drinks.

Additional information, links and downloads

The pharmacy team has shared outcomes and learning through presentations and national events including:

  • The Kings Fund
  • The Royal Pharmaceutical Society
  • The Primary Care Pharmacy Association’s ‘Understanding Government’ conference
  • University of Herts Frailty forum
    • East and North Hertfordshire Clinical Commissioning Group AGM

We presented to Simon Stephens, Professor Sir Malcolm Grant, Nick Seddon and other directors of NHS England including Ian Dodge, Keith Willett and DH&SC senior civil servant Tamara Finkelstein.
Our Vanguard partners, the Hertfordshire Care Providers Association and Hertfordshire County Council also shared our findings.

Learning has contributed to NHSE’s Enhanced Health in Care Homes framework and been influential in developing the recent national NHSE initiative to increase pharmacy professional resources in care homes using the Pharmacy Integration Fund.

The project is now being spread across the Hertfordshire & West Essex STP area, with partner CCGs adopting the model and recruiting pharmacy staff to work in care homes. Resources have been shared and work is currently underway to make data recording consistent across the STP.

Our 'Vanguard' project has its own website to facilitate sharing and provide contacts for enquiries. We held a national workshop and produced supporting materials, provided free of charge. We have encouraged other organisations/people to shadow our work including the Local Pharmaceutical Committee, pre-registration pharmacy students and other CCG staff.

Supporting attachments:

Download the full project pack