Medicines Management in Care Homes Krupa Dave & Caroline Goh Proactive Care Homes Pharmacist Central London Community Healthcare NHS Trust Our Vision: To lead out-of-hospital community healthcare

Aims and Objectives To improve the safe and effective use of medicines in the care home setting To understand some of the challenges facing medicines management in care homes To understand the different roles of Pharmacists in supporting care homes Review common scenarios/ challenges faced in care homes and share ideas of good practice

Medication Errors What percentage of Care Home residents experience at least one medication error? 17% 25% 50% 70% 95%

What is the most frequently reported medication error in care homes 1. Attempting to give 4 hourly medicines too early 2. Attempting to give medicine at the wrong time 3. Attempting to give medicine on the wrong day 4. Attempting to give medicine to the wrong resident 5. Attempting to give medicine that has been discontinued. Where can medication errors occur? Prescribing, dispensing, storage, supply, administration

What is the total cost of medicines disposed of unused by care homes in a year? £1 million £5million £10 million £50 million £ 75 million Ref: Royal Pharmaceutical Society (2014) Pharmacists improving care in care homes

Proactive Care Homes Pharmacist Proactive care home project covering 20 care homes (Nursing homes, residential homes, extra care homes) across Hammersmith and Fulham and West London. The project aims to: Standardise care provision, improving equity of care, Target causes of non elective preventable acute Accident and Emergency attendances, and Ensure a consistent skill set within care home staff by means of identifying and meeting training needs. Training is also provided to Care Home staff members for needs that are identified. In addition, some direct services such as assessment, reviews (including medication reviews) are provided to residents by members of the multidisciplinary team.

Management of Medicines in Care Homes by Pharmacists FACE to FACE LEVEL 3 MEDICATION REVIEWS 9228 interventions (Dec 2013 to May 2016) 7989 (87%) interventions actioned by GP 195x Grade IV (Reversible harm or admission to hospital) and 2x grade V (Averted death or major permanent damage) Medicines Optimisation REDUCE MEDICATION ERRORS Produce Datix Incident Reports Medicines Reconciliation of hospital discharges Monitor omitted & delayed medicines MULTIDISCIPLINARY WORKING Establish GP ward rounds Attend MDT meetings Referrals to/from other disciplines COST SAVINGS £149,937.42 (Net savings) Management of Medicines in Care Homes by Pharmacists MINIMISE WASTAGE Removal of expired medicines Manage excess medication stock REVIEW of POLICIES / GUIDELINES Go through each point ADMINISTRATION SUPPORT Self-administration assessments Crushing medications Changing formulation Covert administration EDUCATION & TRAINING Omitted doses, self-administration, inhaler technique etc, Medication counselling for residents

Patients CARE HOMES PHARMACISTS MEDICINES OPTIMISATION PHARMACISTS Level 3 medication reviews for residents in care homes (Face to Face) Multidisciplinary working Liaise with GPs, practice pharmacists and community pharmacists Medicines reconciliation post hospital discharge Reduce medication errors Education and medication counselling to patients / carers Minimise wastage and cost savings Tailored training to care home staff Support on medication administration MEDICINES OPTIMISATION PHARMACISTS Level 3 medication reviews for housebound patients Develop joint care plan with patients / carers Liaise with GPs, practice pharmacists and community pharmacists Medicines reconciliation post hospital discharge Reduce medication errors Education to patients / carers Minimise wastage and cost savings Multidisciplinary working Patients COMMUNITY PHARMACISTS Process prescriptions and supply medications Provide Medicines Use Review (MUR) and New Medicines Service (NMS) with customers in pharmacy shop Advise on lifestyle and well-being for primary preventions Health checks Liaise with practice pharmacists and GPs on repeat prescriptions and recommendations from MUR and NMS PRACTICE PHARMACISTS Medication reviews in GP practice Support practice to meet QoF targets Medicines reconciliation post hospital discharge Cost-savings through formulary switch Liaise with community pharmacists on repeat prescriptions and recommendations from MUR and NMS Refer patients to care homes pharmacists for level 3 medication reviews

Medicines management in care homes Prescribing medication- e.g. urgent requests Dispensing e.g. wrong medication supplied Supply e.g. None in stock in pharmacy Storage e.g. Controlled drugs, fridge items Administration e.g. swallowing problems, refusing medicines, self Documentation e.g. MAR charts Communication e.g. Of medication changes through care settings. Legal e.g. controlled drugs storage

Scenario 1- Supply Mrs Smith 81 years discharged to your nursing home from hospital on a Friday evening at 5pm. Past medical history: Type 2 Diabetes, Parkinsons disease, Atrial Fibrillation, glaucoma Medication documented to be taken on discharge summary with the following directions. Issues: Hospital did not send the Sinemet tablets (Parkinsons medication) Questions: What are you concerned about? Any issues with the medication list/directions. What are your options? Warfarin Tablets as directed Sinemet 62.5mg four times a day Omeprazole 20mg daily Metformin 500mg three times daily Bisoprolol 1.25mg daily Latanoprost eye drops 1 at night

Actions to be taken Concerns: Dose of warfarin to be given? Which Eye to put eye drops in? Sinemet for Parkinsons –critical medication if missed can disrupt control of Parkinsons disease. Where to obtain supply Hospital – obliged to give minimum 2 weeks supply from Hospital GP/ Out of hours GP Family/friends to bring in medication

Scenario 2- Administration Resident in Care home has been chewing their medication and having difficulty swallowing medicines. GP has advised nurses to crush all medicines, nurses began crushing tablets and opening capsules. Medication List: Questions: What would you do in a NH/RH/EC? What needs to be reviewed and considered? Who would you refer to and why? Alendronic acid 70mg once a week Tablet Adcal D3 Tablet Flucloxacillin 500mg capsule Ramipril 2.5mg capsule Simvastatin 40mg Tablet Omeprazole 20mg capsule

Actions to be taken NH- Nurses are able to Crush tablets RH/EC- Carers cannot crush medication Referral- Is a referral required to speech and language therapist? Contact Pharmacist not all medication can be crushed. Alendronic acid 70mg once a week Tablet- Cannot be crushed harmful and not effective Adcal D3 Tablet- change to dispersible tablets Flucloxacillin 500mg capsule- capsules not to be opening irritant to person opening capsules, liquid available Ramipril 2.5mg Capsule- capsules can be opening and mixed with water Simvastatin 40mg Tablet- tablets can be crushed Omeprazole 20mg capsule- not suitable to be opened reviewed to dispersible tablets.

Scenario 3- Adherence Resident in Extra care home 83 years old. Medical History: stroke, high cholesterol , hip fracture 2008 Ex smoker, previous history of alcohol excess Medication prescribed: On ordering his regular monthly medication you notice that he has not been taking some of his medication and has excess boxes in stock. What do you want to check with the resident?, What are your next steps? Aspirin Thiamine Nicotine Lozenges Paracetamol Lansoprazole Codeine Lactulose simvastatin Movicol

Actions to be taken Review what medication the resident is taking, whether they understand what the medication is for. Refer to GP/ pharmacist for a medication review Medication reviewed by Pharmacist/GP On review/discussion with the resident the following medicines were reviewed: Thiamine – Stopped (was started by Dr when he was drinking excessively – no longer drinks) Codeine – was given in 2008 when he had a hip fracture made him constipated so did not take and no longer in pain Movicol and lactulose- He has not been taking as does not need opening bowels fine. Was started by his GP when he was given codeine Nicotine lozenges- not been taking resident has cut down amount he smokes to 5 /day and continues to smoke does not want lozenges. He was educated on the importance of taking his aspirin, simvastatin and lansoprazole and agreed to continue to take. He requested to have paracetamol as when required if he needed for pain relief. His medication was cut down from 9 tablets to 4 tablets. Medication waste was reduced.

Medicines Management in Care Homes Good medicines management- Robust policies and training in place Identify areas where medication errors can occur Regular Audit of medicines management Reduce medicines wastage Feedback at monthly meetings/ openly discuss and report errors. Highlight residents that you are concerned about to GP/Pharmacist for review. Areas where medication errors can occur- poor communication, prescribing to administration.

Thank You Any Questions?