Sheffield Integrated Care Service Integrated support for complex patients. Sarah Alton Head of Medicines Management Janet Smith Community Matron

Sheffield

Combined Community and Acute Pathway Integration Our patient pathways span the provision of health services across community and acute, including older people, stroke and palliative care. This has provided the opportunity to consider how the delivery of care could be configured and redesigned in the future to transform patient pathway Integrated Community Care Primary Care & Interface Services Therapeutics & Palliative Care Integrated Geriatric & Stroke Medicine Four Integrated Care Teams (ICTs) covering: ICT Nursing 24/7 ICT Therapy ICT Pharmacy Active Recovery (Rehab) Falls Service Podiatry (including forensic and acute) Flexible Workforce Palliative Care: Palliative Care Unit Hospital Support Team Intensive Home Nursing Bereavement Service Lymphoedema Service Continence Tissue Viability TB Therapeutics: Chaplaincy Dietetics (acute/community) Psychological Services SLT (acute/community) Medical Illustration Plus host for: CCA Research Professional Leadership

The Integrated Care Pharmacy Team Pharmacist Team Lead 0.8FTE Clinical Pharmacists 2.0FTE Care Home Support Pharmacist 0.4FTE Pharmacy Technician 1.0FTE

Referral Criteria to Pharmacy  Compliance issues  On 10 or more medications  Difficulties with swallowing  Recently discharged from hospital or intermediate care facility  At risk of falls  Pain review needed  On high risk medicines  Medication related concerns

Activity to date: Reviews Over 500 referrals Apr 14 to March 15 for domicillary review Approx 50:50 clinical:adherence 76% clinical reviews for patients with complex long term conditions

Medicines Optimisation The medicines optimisation hub. Social careHospitalNurse Community pharmacist GP practice MDT working to improve medicines management and patient outcomes

COPD Initiative From October 2015 to April 2016 All patients with diagnosis of moderate to severe COPD in one Community nursing team Initial review and CAT assessment, follow up at 3 and 6 months Evidence based – GOLD criteria – Isle of Wight initiative

Education and Training Medicines management training as part of core clinical skills for all community staff Ad hoc training on medicines issues LTC medicines management training provided – Heart Failure – COPD – Diabetes

Case Study 1: Patient referred due to poor compliance with her monitored dosage system (MDS) A home visit from the Integrated Care clinical pharmacist was arranged. Patient had carers in morning to assist with showering and dressing The patient had good compliance with her morning meds however this was poor at lunchtime and hit and miss with evening meds. The medications she was non-compliant with included furosemide, lansoprazole and simvastatin. The patient explained she went out shopping, going to coffee mornings and lunch clubs. The patient was taking two beta-blockers, one had been discontinued during a recent hospital admission and alternative started, but this had not been updated at the GP surgery.

Questions What factors would be considered on first assessment of this patient? Who should be involved in discussions regarding this patient? What recommendations might be made to support this patient?

Actions Taken Discussion with patient to find out her needs, community pharmacist, GP and carers Discontinue one of the beta-blockers Furosemide discontinued,nurses to monitor Rationalise medications to once a day in the morning- simvastatin switched to atorvastatin Carers to prompt with meds in the morning Second visit planned to coincide with delivery of updated MDS. Patient counselled on the changes to her meds. Third visit arranged after a few weeks to assess compliance with the new MDS. Patient’s compliance was much improved.

Case Study 2 Patient referred to the pharmacy team Patient receiving ongoing district nurse visits for the application of a Fentanyl patch every 3 days. The patient had an existing care package and received four care calls a day to administer medications, excluding Fentanyl

Questions What factors would be considered on first assessment of this patient? Who should be involved in discussions regarding this patient? What recommendations might be made to support this patient?

Actions Taken Home visit from clinical pharmacist Medication review of all meds Discussion of options with patient and assessment of circumstances- a little persuasion resulted in the patient agreeing to the care company taking over the application of the fentanyl patch Contact care company superviser to request application of Fentanyl patches was included in the meds admin package. Reduced need for a nurse visit.

Benefits of Joint Working Wider Skill Mix Broader input into Long Term Condition Reviews MDT approach adds value and improves outcomes for patients Better understanding of each others roles Members of the team linked to localities leads to improved communication and improved rapport Shared knowledge and skills

“Better than a BNF”

Changes to nursing teams Changes to pharmacy team Small team spread thinly Taking time to refer Communication across teams Capacity

Future Developments Greater input into LTC reviews ICT pharmacy team caseload and management of patients Increased input into palliative care and end of life patients Prescribing Widening referrals Increased integration with social care and locality working

“ Without change there would be no butterflies”