A domiciliary medication review service – ‘MESH’ Su Wood – Prescribing Support Services suei.wood3@bradford.nhs.uk

Aim to: Understand what the Bradford MESH service is Know how the referral system was developed Understand the service delivery Know the impact the service has had and the economic benefit to the NHS Look at a domiciliary medication review service in relation to the NHS England pilot scheme

Plan Overview of the current pharmacist led MESH service Challenges in running the service Opportunities for MESH service development National context MESH: supporting the CCG objectives/vision Group discussion Feedback and Q&A Summary

What is the problem? What happens to a prescription once it has been issued? Who knows? An unmet need

What is the problem? A typical case Excess medicines found in a home Included 58 insulin pens, 15 boxes test strips & 17 boxes lancets 34 bottles of Sno tears (many half used or out of date), 9 Seretide 125 inhalers & 10 Ventolin inhalers

What is the problem? 50% of patients with chronic diseases in the developed world are non- adherent. The magnitude and gravity of non-adherence is such that greater worldwide health benefit could be gained through improving adherence to current medicines than developing novel treatments. The consequences are waste, morbidity and hospital admissions. World Health Organisation. adherence to long term therapies. evidence for action. Geneva: WHO; 2003

What is the problem? So that could mean for 50% of prescriptions: Likelihood of clinical benefit reduced Risk of harm increased High cost for the NHS

How can a pharmacist in primary care help?

Who are we? Prescribing Support Services: a multidisciplinary team providing a range of medicines management and optimisation services in primary care ‘MESH’ – MEdicines Support at Home – care home and domiciliary medication review.

Domiciliary review service model REFERRAL Referral from GP, integrated care , Social service. BRI. Virtual ward or community service providers 10 or more meds, high risk medicines or multi morbidity Computer based level 3 medication review Identification of key priorities Arrange face to face review Undertake domiciliary or care home review Complete action plan including holistic interventions ..liaison with specialist nursing teams, social services, primary care, family & carers Follow up key actions : engagement with service providers Focus on patient safety /admissions avoidance DISCHARGE

High quality medication review delivered by experienced clinical pharmacists To comprehensively review complex polypharmacy patients To support prescribers with deprescribing agenda To review a patient’s medicines holistically addressing and discovering: Why and when medicines were started Clinical issues – interactions, doses, monitoring, approprtieness of tx, untreated indications Adherence issues – unintentional/intentional? Understanding patients health beliefs/attitudes towards medicines Ordering, supply and waste reduction of medicines To ensure the medication reviews are informed by current policy and guidance on medicines – MHRA/NICE/Safety alerts To enable clinical priorities to be addressed, such as antipsychotics in dementia, reducing anticholinergic burden, inhaler issues, “Dosette” box issues

Outcomes – dependent on resource put in   Bradford Districts CCG Bradford City CCG population  330,115  118,567 Pharmacist resource 1.6FTE 1.4FTE Net annualised savings £150,000 £140,000 Number of dom reviews 772 957 Adherence issues 36% 32% Reducing risk of harm 544 tests ordered 30 antipsychotics in dementia stopped 58 sedatives stopped/ reduced 76 anticholinergic burden reduced 12 NSAIDs stopped/ reduced 550 tests ordered 16 antipsychotics in dementia stopped 42 sedatives stopped/ reduced 255 anticholinergic burden reduced 29 NSAIDs stopped/ reduced

Cost saving Dependent on the resource put in Annualised drug cost saving reported Not reported savings on - Reduced hospital admissions - GP time - Nurse time - Social care time - Carer burden

Recurring themes - inhalers Example – ‘Approx 5-6 inhalers in use including Flixotide 125mcg, Seretide 125/25, Clenil 200mcg, Salamol 100mcg & Ventolin 100mcg mdi using 1 puff, four times a day of each inhaler.’ Photo ‘excess’ inhalers – lost clinical benefit and waste value £1,400 140/191(70%) technique corrected, 37/191(20%) inhaler device changed How the MESH pharmacists are tackling this - Informing GPs or respiratory nurses of non-adherance - Educating patients on inhaler technique - Providing written instructions to aid memory - Follow up visits to check corrections are being maintained - Involving relatives and formal or/informal carers in supporting patients

Recurring themes – ‘Dosette Box’ issues Photo: multiple boxes in the home with only the odd dose taken out of any of them How MESH pharmacists are tackling this - Ensuring that an ‘MDS’ is appropriate and the best way to help the patient manage their medicines - Using the medication review as an opportunity to rationalise medications and implementing deprescribing where appropriate - Making links with community pharmacy, social care and GP surgeries to ensure good communication around medication issues - Practices now encouraged to ask the MESH pharmacist to review before starting a Dosette box where capacity allows

Recurring themes – ‘Waste’ - Excess medications in patient’s own home £58,000 of excess meds found last year How MESH pharmacists are tackling this - Patient/family/carer education when excess medicines removed. - Working with patients to run down stocks and implementing a system for evaluating if more medicines are needed. - Removing items from or adding messages to repeat templates indicating excess stock and date item next needs to be ordered. - PSS waste poster being developed to put up in GP surgeries/pharmacies. - MESH pharmacists’ contact details supplied to community pharmacists and GP receptionists if they identify medication over-ordering or potential hoarding

Stakeholder feedback Patient: “It’s much easier now only taking things once a day, I get them all out of the way in the morning and I haven’t forgotten once” “The reminder chart really helps and it’s handy on the fireplace” GP “Excellent job. Now why did we not acquire your services a long time ago. Carry on good work.”

Challenges in setting up this service: workforce Experienced clinical pharmacists Clinical training and experience essential Communication with patients/ carers and other HCPs Team work Lone working Adequate resource Governance Safeguarding

Challenges: how do we find patients? GP practice – known patients, searches (e.g. ≥ 65yrs, 10 or more meds, inhalers, housebound) Referrals (S1 task and email to MESH pharmacist) are received from: • GP • Integrated care service • Community pharmacists • Social services – assessment team • Social services – provider team • Hospital – BRI • Home for Hospital • Virtual ward • Pulmonary rehab • Physio/ OT

Challenges: multi-disciplinary communication In the review process, MESH pharmacists work with: • Patients • Relatives/carers • Community pharmacists • District nurses • Heart failure nurses • Social services – assessment team • Social services – provider team • Hospital ward staff • Hospital consultants • Hospital medical secretaries • Respiratory • Elderly care discharge • Virtual ward • Interface

Challenges: KPIs Data collection: cost saving and clinical parameters, error reporting and patient ‘stories’ Reporting: quarterly Clinical benefit outcomes: risk reduction markers, patient stories Cost saving outcomes: annualised drug cost saving Patient and NHS stakeholder feedback

Challenges going forward ‘Over 85 population in Bradford has grown by 17% and will grow by 44% in the next 5 years’ – inevitable increase in polypharmacy patients Increased resource needed for equity to all practices, to manage increased referrals from primary care, to manage increased in-reach/ out-reach requirements from secondary care. Integrated care groups – aiming to a greater presence Polypharmacy and de-prescribing agenda

Fits with national context Focus on integrated care Admissions avoidance Polypharmacy and de-prescribing agenda NICE guidance on medicines optimisation

MESH supporting the CCG agenda Frail elderly Patient-centred care Self-care Integrated care Admissions avoidance Polypharmacy and de-prescribing

Discussion in groups What experience is there is the group, if any, of this type of service? How do you see a domiciliary medication review service in your area? What are the challenges to setting up a domiciliary medication review service in your area? How would a domiciliary medication review service be good for a General Practice Pilot Site?

Summary – domiciliary review for the pilot scheme Improve medicines safety Improve patient outcomes Improve management of long term conditions Reduce GP workload Improve communication between pharmacists, GP practices, social care etc Increase patient confidence in pharmacists Increasing roles of practice pharmacists

Summary – why you need to have a domiciliary medication review service There is an unmet need There is no point in prescribing and issuing medicines if they are not taken, both clinically and financially