1. 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 /

2. #WeStopMeds

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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/ /06/2017
Week 5: 1-day Workshop
05/06/2017
Week 6-11: Second onsite visit
13/06/ /07/2017
Week 12: Half-day Workshop
17/07/2017
Week 13-22: Third (optional) site visits/phone call
24/07/ /09/2017
Week 23-24: Measurement data follow up
18/09/ /09/2017
Week 25: Celebration Event
03/10/2017
Project Evaluation
09/10/ 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

12. 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.

13. 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.

14. 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

15. 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

17. 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

18. 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

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

20. 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

21. 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

22. 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

23. 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

24. 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”

25. 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

26. e: academy@yhahsn.nhs.uk
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