Medway Care Home Team Dr Sanjay Suman – Consultant Geriatrician - Medway Foundation Trust Prina Sahdev – Care Homes Pharmacist - Medway CCG

Background Visiting Medical Officer role replaced by Care Home Team 12 month Pilot 12 nursing homes covered Approx 470 beds

Integrated Team Pharmacist Medway CCG Medication Reviews, Medication Reconciliation, Reduce Wastage, Support with CQC visits, Training Advanced Nurse Practitioners x 2 Medway Community Healthcare Reduce GP workload, Support Nursing Homes, reduce Hospital admissions, training End Of Life Facilitators Medway Community Healthcare Advance Care Plan, Training, Support with Syringe Drivers, Support residents and their families, supplementary prescribers Consultant Geriatrician Medway Foundation Trust Support with virtual ward rounds, Medication reviews, Education, support

Pathway Nursing Home Care Home team Admin (Triage) Nurse Consultant Geriatrician (Weekly Virtual Ward Round) Community teams (Diabetes, Respiratory etc) Pharmacist GP End of Life Facilitators

Key Performance Indicators 15% reduction in ED attendances (40 attendances) 15% reduction in ambulance conveyance (40 conveyances) Reduction in non- elective admissions by 0.85 ratio to ED attendances (34 admissions) Achieve £100,000 prescribing savings in nursing homes 100% of residents identified as end of life and that have an advanced care plan in place Residents supported to achieve their preferred place of death Increase nursing home satisfaction

12 Month Review KPI including pilot target Target at 12 months Achieved at 12 months 15% Reduction in ED attendances (40)40158 Achieve £100,000 Prescribing Savings£100,000£142,386* 100% Residents identified as end of life with and advanced care plan in place 100% 15% Reduction in ambulance conveyances (40) 40158

Pharmacy Savings 356 Patients reviewed 84 Average age of patient 6 Average number of medications 4 Average number of recommendations made / review £432 Average saving per review ** Central Nervous System, Nutrition, Cardiovascular £££ Nutrition and Woundcare

Nurse Perspective Resistance to input from NHsResistance to end of VMO schemeData collection – patchy, time constraintsGetting information from Nurses in homesHosted independent Forums - includes trainingRelationships built successfullyClose working with GPs

Pharmacist Perspective No resistance to inputWillingly accept advice and feedbackAudit visits to prepare for CQC audits and to support good practice Close relationship with GP practices – rapid access to information and advice Difficulties with procedures – each home is individualMedication reviews in line with Local Formulary and initiatives

Lessons Learnt Pilot extended for further 6 months Benefits from proactive work not evident Internal Referral sheet set up Communication within integrated team not recorded by nurses Residential Beds to be covered by CHT Residential units in care homes skewed figures Workshop organised Pathways drafted Lack of clinical pathways

Future Hopes Better links with acute frailty pathway – From front end of hospital Early facilitated discharge – from wards Better links with Out of hours teams – follow up with end of life patients

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