European Innovation Partnership on Active and Healthy Ageing Medicines Optimisation Best Practice Professor Mike Scott Pharmacy and Medicines Management Centre Northern Health and Social Care Trust Titanic Centre 30 th January 2014 Belfast

Time line  Integrated Medicines Management (IMM)-patients over 65 years of age  2005-present Pharmaceutical Clinical Effectiveness  Safer Patient Initiative (International Healthcare Improvement (IHI) )  present Innovation Programme

How was it initiated  Business case was produced indicating the work that was proposed  Resources required to undertake  Process measures  Clear outcome measures  Research base methodology

How Was Political Support Obtained  Northern Ireland Executive Innovation Fund proposal (1999)  Citizen Benefits for older people predicated on previous local evidence

How was financial support secured  Executive programme funds Euro 720k first three years for the pilot  Based on positive outcomes further investment over the next five years Euro 4.8million  Return on Investment:  For very 3 euro invested per head of population 15 Euro returned  Innovation programme 840k Euro

Stakeholder Buy -in  All relevant stakeholders were involved at the outset  Integration of the key healthcare team members  In the Pharmaceutical Clinical Effectiveness Programme there is a multidisciplinary collaborative approach to reach consensus on clinical products based on safety and quality

Implementation of the technical solution  Comprehensive education and training  Integration with medical and nursing colleagues in both primary and secondary care  Standard operating procedure development  Documentation development  Skill mix and role clarity  Software development for both operational use and process and outcome capture  Robust research based methodology-University linkage

How change management was implemented  Extensive pre implementation discussion with all key stakeholder groups  Workshops and presentations  Roadshows  Oversight group  Operational group

AIM  To optimise the benefits that patients gain from prescribed treatments through innovative technology-supported solutions delivered through intra professional and intra sectoral systems change

Medicine Optimisation Objectives Right Drug  Selection  Matrix methodology  STEPSelect (Safe Therapeutic Economic Pharmaceutical Selection) optimise acquisition cost  Formulary management  Guideline development

Medicine Optimisation Objectives Right Patient  Re-engineered clinical pharmacy services in the hospital setting (older patients)(EPICS- Electronic Pharmacist Clinical Intervention System)  Focus on admission,inpatient stay and discharge  Medicines appropriateness index  Consultant care of the elderly pharmacists in intermediate and nursing home settings  Predictive risk modelling in the elderly

Medicine Optimisation Objectives Right Dose  Medicines reconciliation between sectors (Writemed software)  Medicines reconciliation between professionals  Medicines reconciliation at all transitions of care  Development of the Emergency Care Summary(ECS) and then Emergency Care Record(ECR)

Medicine Optimisation Objectives Right Time  Commitment to EIP –AHA to improve adherence to prescribed treatments  HSC assessment tools  Adherence solutions both technological and patient focussed  e -health strategy  Development of a technology supported intervention via the Small Business Research Initiative(SBRI)

Results (1)  Reduced length of stay by 2 days  Reduced readmission rate  Reduced length of stay on readmission 5.8 days  Improved Medicines Appropriateness Index (17.48 to 5.69)  Reduction in 4.2 errors per admission kardex  Reduced medicines administration error rate(8.3% to 1.3%)  Reduced discharge error rate from 22% to less than 1%

Results (2)  Nursing home:  Four interventions per patient  Improved MAI  Reduced costs of £48 per month per patient  Reduced ED attendances  PCE programme achieved 168 million Euro of efficiency gains  Improved satisfaction with the system by patients

Added Value-Integrated working  Enhanced communication:  Between health care professionals  Between sectors  Between community and voluntary sectors  Traditional barriers broken down

Efficiency Effectiveness Sustainability  211 pharmacists and technicians have been trained across sectors  Northern Trust has a multi faceted adherence service  Software developments have improved the efficiency and effectiveness  In place for 13 years  Adoption in other countries  Learning visits testify to the recognition of the effectiveness and efficiency

Competitiveness Market Growth Economy  ENABLING TECHNOLOGIES;  STEPSelect - Digitalis Ltd Amsterdam  EPICS(Electronic Pharmacist Clinical Intervention System) –Yarra Software Ltd Belfast  Writemed (Medicines reconciliation software programme) -Yarra Software Ltd Belfast  Bespoke locker development -Hospital Metalcraft England

Competitiveness,Market Growth Economy  Clinical rules –Digitalis and Orbisch Medisch Centrum Sittard Netherlands  Intelligent Alerts - Yarra Software Ltd Belfast  Local Automated Microbiology Pharmacy Surveillance System (LAMPS) Yarra Software Ltd Belfast  Other HCAI related, Iskus Health- Dublin,Arran Healthcare –Dublin, Goldshield- USA 

Success factors(1)  Early stakeholder engagement  Willingness to change systems and processes  Good strategic and operational oversight

Success Factors (2)  Robust methodology in terms of both clear process measures and outcomes  On-going reports and dissemination of progress including conferences and publications  Development of enabling technologies  Quality improvement model of change

Success Factors (3)  Better engagement with researchers  Better values and outcomes though engagement with Pharma  Concordance improvement though partnerships with patients and carers  Improved dialogue with the technology industry  Utilisation of Government innovation incentives in pursuit of the health and well being agenda

Barriers to innovation  Underdeveloped pharmacy service focussing on distribution rather than patient facing  Lack of awareness of current system deficiencies by other healthcare colleagues and the skill set of pharmacy  Lack of technical staff  Absence of training material  Enabling technologies

Transfer Success  Another Trust in Northern Ireland  Regional in Northern Ireland  Numerous Trusts in England  Uppsala in Sweden  Skane in Sweden  Tallaght Hospital in Southern Ireland  Drogheda Hospital In Southern Ireland

Education and Training  Colleagues from  Sweden  Norway  South of Ireland  Erasmus programme with Poland  Programme with the Spanish Hospital Pharmacists Association  Exchange programme with Orbisch Medisch Centrum Sittard,Netherlandss  Jordan  Numerous visits from English Colleagues  New Zealand

Lessons Learnt  Realistic timelines  Full stakeholder engagement and ownership  Ensure that robust measures are determined at the outset  Awareness of the difficulties in developing enabling technologies from both a hardware and software viewpoint  The importance of ensuring paper based methods work before automating  Identifying commercial partners

Action Plan(A1) Prescription and Adherence to Medical Plans  Improve patient adherence to care plans  Empower patients and caregivers  Deliver improvements in the healthcare system to promote adherence  Contribute to the research methodology on ageing and adherence  Foster communication between different partners to improve adherence

Work to date  Delivered transferrable process changes in hospital and interface aspects  Delivered enabling technologies with EU companies  Delivered robust evidence  Delivered enhanced communication between key partners at transitions of care  Initiated work on older patients in cohorted settings in the community

Medicines Management Support Service Project  To improve outcomes form prescribed medicines by ensuring safety and quality in provision of adherence support for older people who are living in their own homes  NHSCT and SEHSCT,Community Pharmacists

Medicines Management Support Service Project  Develop a referral mechanism  Refine the assessment tool  To identify a range of solutions  Explore feasibility of monitoring and follow- up  Develop governance arrangements  Problems –access,concordance,clinical

Small Business Research Initiative (SBRI)  For individual use  For the use of people living in their own homes  Tailored to the individual’s needs  Easy to use  Supported by monitoring and data tracking  Capable of incorporation into patient care pathways  Capable of interface with HSC ICT systems

EIP  Valuable potential collaborators to complete the gap closure  Enables awareness of other work and a much more cohesive way to go forward  Building of links with other groups in your specific area via EIP members  Dissemination mechanism  Formulate research questions  Bids for Horizon 2020 funding

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