Sujo Anathhanam Megan Humphreys Safer prescribing in frailty and empowering independence in older people Sujo Anathhanam Megan Humphreys 2 Hf funded projects as part of their innovation for improvement program SPF is in a more mature position to be replicated SSC feasibility study looking at joint working with VCS & Primary care Using eFi to case find academy@yhahsn.nhs.uk / 01274 383966 www.improvementacademy.org

#WeStopMeds

Polypharmacy: the problem 1/3 of ≥ 75 year olds are taking at least six medicines. 6% of admissions to hospital are drug related. 50% of medicines are not taken as prescribed. Some general statistics about polypharmacy. Older adults with frailty often not in the trials Outcomes are not usually frailty specific e.g. falls, fractures Trials are rarely about stopping drugs

Ageing population Multi-morbidity More frailty Poly-pharmacy Side effect burden Some general statistics about polypharmacy. Older adults with frailty often not in the trials Outcomes are not usually frailty specific e.g. falls, fractures Trials are rarely about stopping drugs

APPROPRIATE POLYPHARMACY “Prescribing for an individual for complex conditions or multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence” PROBLEMATIC POLYPHARMACY “Prescribing of multiple medicines inappropriately, or where the intended benefits of medications are not realised” Some general statistics about polypharmacy. Older adults with frailty often not in the trials Outcomes are not usually frailty specific e.g. falls, fractures Trials are rarely about stopping drugs King’s Fund, 2013

Aims Reduce inappropriate prescribing for older people living with frailty Inappropriate prescribing defined as: unnecessary (without indication or benefit) unwanted (by the patient) or unjustifiable due to its risk/benefit ratio. In primary care Person Centred approach Explore primary care as suitable place to make these changes

Methods 12 independent GP practices in 5 CCGs within Yorkshire Moderate or severe frailty by eFI Conversations in surgeries, home visits and care homes Training package Flexibility within practices regarding approach

Project Teams Our original aim was to recruit 12 teams but as we thought that some practices might drop out we went with 16 at the start and during the course of the project 4 did drop out primarily due to staff shortages. Practices from Scarborough to Hawes in the dales and as far down as tadcaster and west again to Skipton and Keighthly in west Yorkshire. Population ranged from the smallest been 4000 pop uo to about 50,000 population - Priory in York. This just demonstrated that size was not in itself a barrier. Varied skill set within practices

Q.I. Our approach Provide tools Identify barriers Our original aim was to recruit 12 teams but as we thought that some practices might drop out we went with 16 at the start and during the course of the project 4 did drop out primarily due to staff shortages. Practices from Scarborough to Hawes in the dales and as far down as tadcaster and west again to Skipton and Keighthly in west Yorkshire. Population ranged from the smallest been 4000 pop uo to about 50,000 population - Priory in York. This just demonstrated that size was not in itself a barrier. Varied skill set within practices

The Tools UK Polypharmacy Guidance from: NHS Scotland, Kings Fund, NHS Wales, PrescQIPP NHS Programme Evidence-based tools: STOPP/START tool 7 Steps approach No Tears tool Medicines Appropriateness Index Our original aim was to recruit 12 teams but as we thought that some practices might drop out we went with 16 at the start and during the course of the project 4 did drop out primarily due to staff shortages. Practices from Scarborough to Hawes in the dales and as far down as tadcaster and west again to Skipton and Keighthly in west Yorkshire. Population ranged from the smallest been 4000 pop uo to about 50,000 population - Priory in York. This just demonstrated that size was not in itself a barrier. Varied skill set within practices

Project Timeline ACTIVITY START Project Set-up 01/01/2017 Invitations to Participants Sent 16/02/2017 Deadline for expressions of interest 24/03/2017 Inform selected teams 27/03/2017 Develop materials for workshop 03/04/2017 Week 0: Orientation 28/04/2017 Week 1-4: First onsite visit 05/05/2017 - 02/06/2017 Week 5: 1-day Workshop 05/06/2017 Week 6-11: Second onsite visit 13/06/2017 - 14/07/2017 Week 12: Half-day Workshop 17/07/2017 Week 13-22: Third (optional) site visits/phone call 24/07/2017 - 15/09/2017 Week 23-24: Measurement data follow up 18/09/2017 - 29/09/2017 Week 25: Celebration Event 03/10/2017 Project Evaluation 09/10/2017 - Ongoing Our original aim was to recruit 12 teams but as we thought that some practices might drop out we went with 16 at the start and during the course of the project 4 did drop out primarily due to staff shortages. Practices from Scarborough to Hawes in the dales and as far down as tadcaster and west again to Skipton and Keighthly in west Yorkshire. Population ranged from the smallest been 4000 pop uo to about 50,000 population - Priory in York. This just demonstrated that size was not in itself a barrier. Varied skill set within practices

Average number of items on repeat prescription We identified and addressed barriers to changing prescribing behaviours. There was a 6% reduction in prescriptions per person, 1/3 of the stopped items were high risk (likely to cause harm). The conversations with patients were reshaped. Attitudes to prescribing for people with frailty changed improving the culture of care.

Outcomes in Primary Care We identified and addressed barriers to changing prescribing behaviours. There was a 6% reduction in prescriptions per person, The conversations with patients were reshaped. Attitudes to prescribing for people with frailty changed improving the culture of care.

Quotes “The work is worthwhile as a lot of these patients are missed due to being home visits and not likely to come to surgery for reviews or follow ups.” GP “The most important part of the project is the legacy it has left” GP “I hadn’t fully appreciated the size of the problem nor the barriers to change” Project team

The future Spread Opportunities GP contract We are designing a model for spread: -Define a manageable sized cohort. -Analyse practice barriers to reducing medication burden. -Use the tools that have been shown to work to overcome barriers. -Measure the improvement. -Supported with facilitation Opportunities GP contract Health Education England GP trainers North Yorkshire CCGs AHSN network – Flagship frailty project Practice to practice SPS repository for NHS England Connected Health Cities Awards – HSJ Value 1 team won AHSN award at the III Funding ended – looking at spreading further with a lighter touch & to see if with this its feasible

The idea Self-management support interventions not routinely available for older people living with frailty Feasibility of joint working between primary care and voluntary sector

Intervention delivery Eligible people were: over 65 years at risk of mild frailty using eFI high users of primary care. Invitation letters sent out by the practice. Offered consultation with an Age UK Supporting Self-Care coordinator Telephone or face to face at practice Development of service delivery & presentation of info throughout project, pulling on PPG, avoidance of use of word old & frailty

Service provision Guided conversation Motivational interviewing techniques Individual plan agreed Further support and signposting to local services where needed

Results: take up 168 people were offered the intervention 108 expressions of interest 106 people took up the offer 52% female; 48% male No significant differences between those who took up the intervention and those who didn’t

What did the offer look like? 106 took part 95 face to face consultations 25 follow up telephone consultations 1 additional face to face consultation 2 additional face to face consultations (motivational interviewing) 11 telephone consultations

Sign posting & support Age UK services: Advice & support Help at Home Befriending Aged Veterans Walk from Home Independent living centre Local Healthy living charity & Social Prescribing team Local clubs & groups Local Authority Falls prevention Weight management Alzheimer's Society Online support & IT skills Audiology Dental Health

What did staff think? “Some patients were already looking after themselves; may have been better received by the moderately frail” Advanced nurse practitioner “Very proactive exercise for staff to work with Age UK. We have enjoyed the opportunity and hope to continue these relationships beyond the completion of the project” Practice manager “An initial consideration was how the integration between the voluntary and community sector and primary care teams might work but this has been a success rather than a barrier … information governance systems could perhaps be re-examined” Age UK coordinator

What did patients think? “I came away feeling confident” “I felt encouraged that someone cared” “Just knowing that there is someone there and how to get in touch with them is a great help … it’s nice to know what is available if we do need it but we don’t feel like we need any help in any particular area at the moment “I was pleased to be chosen, glad to be asked … surprised that with all the cost cutting the practice was able to offer this service”

Findings and next steps Refinement of target group Data being analysed regarding primary care utilisation and patients’ self-rated self-care ability Resource would be needed to support administrative aspects Joint working between primary care and voluntary sector is feasible Both SMP and Age UK interested in building this work and developing model further

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