The London Older People Service Development Program (LOPSDP) The ‘Medicines Management’ Project (January to July 2003) Lelly Oboh Project Co-ordinator

Integrating medicines management into the Single Assessment Process (SAP) Patient Case Selection Social services staff, Nurses, Occupational therapists, etc Initiate SAP Social services or health staff Continued Care Case manager or care coordinator (health or social service staff) The Medicines Management Project In-depth Medication Assessment Assessing Pharmacist Provide Pharmaceutical Care Package Community Pharmacist NurseGPCarer London OP Program Referral Pathway

Objectives  To pilot trigger medicines questions and an in- depth assessment tool with the SAP  To develop a referral pathway  To develop a communication pathway between the older person’s case manager (care coordinator, pharmacists and others  To identify, train and support a cohort of pharmacists to undertake detailed medication assessments and provide pharmaceutical care packages  To develop a monitoring and review process  To achieve improved medication outcomes for older people

4 medication trigger questions I need help getting a regular supply of my medicines Sometimes I do not take my medicines the way the doctor wants me to (I can swallow and use all of my medicines and get all of the medicines out of their containers) There are some medicines that I cannot get out of the containers Realistically I think some of the medicines I take could work better

1. KEY FINDINGS - 4 Trigger Questions (4Qs)  4Qs are appropriate to identify vulnerable OP with pharmaceutical care needs within SAP  4Qs can be adapted to suit needs of OP and assessor  None of the 4Q identifies those with swallowing problems  Trained SAP assessors can refer appropriately to a pharmacist  Using district nurses works well  A&E not a suitable place to ask 4Q  Incorporate 4Qsinto contact and overview assessments  Revised 4Qs  Adequate training is required for those who carry out initial assessments  4Qs can be used as part of discharge plan

2. KEY FINDINGS - Developing referral and communication pathways  OP care organisers can contribute positively to the SAP  A multidisciplinary approach to the SAP process is beneficial  Faxing or posting standard forms/letters work well.  The care plan is a useful way to communicate the OP’s needs and proposed action plan between all concerned  Role of OP care coordinator is vital to ensure adequate communication  Contact and communication protocols with the OP, care organiser, GP, community pharmacist (CP) social service should be developed prior to launch  Communication loops should be closed  The care plan should be sent to those involved as needed

3. KEY FINDINGS - Pharmacist undertaking the in-depth assessment  Primary care and community pharmacists (CP) with the specified competencies can carry out the in-depth assessment using the appropriate tool  Good communication, and organisational skills and local knowledge are essential  Further training and support is needed to fully achieve competencies  CPs need more clinical input  PCT should resource specialists OP pharmacist to carry out in-depth assessment, train and support other pharmacists  Train/support local network of pharmacists to deliver integrated Medicines management services (MMS)

4. KEY FINDINGS – in-depth Assessment tool 1  User friendly, thorough and appropriate  Identifies OP/carers needs, determines priorities and allows development of a care plan to meet needs  Care organisers can contribute to the development of the care plan  Identified that majority of OP assessed had a form of visual limb or memory impairment or swallowing difficulties and complex social needs  OP’s home is an ideal place to conduct assessment  Assessor must have skills to reflect on assessment to ensure that care plan will help to meet identified needs  Care packages must be developed to provide practical solutions to problems  Assessments must be carried out in suitable environments, not in the dispensary

4. KEY FINDINGS – In-depth Assessment tool 2  OP relied heavily on good will of care organisers  No adequate backup systems in place if unavailable  risk  Majority not taking medicines at all or as prescribed  Gap in knowledge of why and what medication is for  non compliance  Medication issues identified in all areas highlighted in OP NSF medicines document  Support CPs to provide backup systems to reduce risk  Develop local systems for regular medication review  Develop systems for CPs to regularly monitor OP knowledge and compliance with medication

5. KEY FINDINGS - Community pharmacists providing packages of care  Care package can be developed from care plan  Assessing pharmacist liasing with CP to develop care package works well  Most OP had a good relationship with a local CP and preferred to use their services  CPs were already providing a certain level of MMS  Variation in structure and reimbursement  Minimal training required for CP to provide care package  Vulnerable OP with a package of care OP advised to register with a local CP  PCTs to ensure there are protocols to ensure MMS are delivered to appropriate standards  PCTs to explore innovative approaches to ensure capacity within community pharmacy to deliver care packages

6. KEY FINDINGS - Indentifying unmet needs and better outcomes for OP  Identified met and unmet pharmaceutical care needs in the 4 areas  Analysis of assessments and evaluation show benefits to OP- supported services, better understanding of their medicines, informed decision making, feeling respected, improved prescribing  Partnership with OP and their carers and among professionals  Further evaluation of outcomes for OP  Systems for more effective sharing of this information among health and social care

RECOMMENDATIONS - Training Develop multidisciplinary training packages to enable  PCT to secure funding to support care packages, understand the value of MMS and risk of not providing MMS  PCTs develop protocols for good communication systems between OP and those involved in their care  OP to access/engage in new services and work in partnership with health and social care personnel  Care organisers to know where and how to get help, access medicines information and resolve simple medicine problems  Social services and voluntary organisations to realise the cost effectiveness of domicillary care, role of pharmacists in medicines management and understand the health system

RECOMMENDATIONS - Training Develop multidisciplinary training packages to enable  SAP assessors to understand the principles behind the 4Qs to identify OP with pharmaceutical needs and the role of pharmacists in medicines management  CP to identify unmet needs, access expert support, time management, access funding for new service, understand local support networks for OP  Specialist pharmacist to reflect on assessment and identify own needs to meet competencies  GPs to realise benefit of team working, understand MMS and how to access

RECOMMENDATIONS- Next steps  Propose a model of spread and sustainability that would fit into existing local medicines management initiatives  Explore options and support the 3 sites with roll out strategy  engage key people in PCTs and social services responsible for implementing OP services  Disseminate learning across London through the London Older People pharmacy network (OPnet) along with other networks and organisations  Gather the views of older people, carers and key individuals  Carry out an evaluation to measure outcomes for OP  Develop a communication strategy to ensure that the findings and learning from the project are disseminated to the relevant individuals and organisations identified  Write full report by November 2003 (include outcomes for OP)

RECOMMENDATIONS- The Future  Validate 4Qs  Validate pharmacist competencies framework  Accreditation for SAP assessors and in-depth assessors  Electronic assessments  Link with new pharmacy contract, LPS, repeat dispensing  Full integration of pharmacy into SAP