Leading Across Boundaries

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Leading Across Boundaries

• Getting the Balance Right
• Medication Review Referral Initiative
• It is estimated that the current cost of unused
  or unwanted medicines exceeds 100 million
  annually. ..The person fails to get the benefits
  they should . . At worst, the person suffers
  poorer health outcomes and increased morbidity,
  and the medicines are wasted.

2008 White Paper Pharmacy in England building
on strengths delivering the future
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Where we are!
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Leading Across Boundaries Team

• Strong network of 9 health and social care
  professionals
• Ewen Sim (GP Birkenhead)
• Jasmeen Islam (PCT Prescribing Adviser)
• Cathy Gill (Adult Social Services)
• Melanie Carrol (Local Pharmaceutical Committee)
• Tee Weinronk (PCT Community Pharmacy Lead)
• Geraldine McCaffrey (WUTH Hospital Pharmacist)
• Linda Lowe (Community Therapy Services)
• Sue Smith (Practice Nursing)
• Kate Newman (Practice Pharmacist)

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Our Vision
Improve the health and wellbeing of the local
patient population
Robust partnership working across the boundaries
of health and social care
Reduce admissions and maintain independent living
Prioritise patients with the greatest need for
review
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National Drivers

• Pharmacy in England White Paper
• 1 in 20 admissions preventable with proper
  medicines use
• Preventable harm from medicines costs 750
  million (NPSA)
• Confusion following medication changes while in
  hospital
• Poor use and wastage of medicines
• side effects which deter people from taking their
  medicines
• over ordering and hoarding
• Patients may not understand medicine and will not
  take it
• Target reviews to meet local health priorities

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National Drivers

• Putting People First
• NICE Clinical Guideline 78 - Medicines Adherence
• High Quality Care for All
• NHS Next Stage Review final report (Darzi
  Report)
• Working across boundaries to develop a
• local NHS which works with partner
• organisations locally, to deliver high quality
  
• care and reduce health inequalities

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Local Drivers

• NHS Wirral Strategic Plan 2008 2013
• Health inequalities
• Falls prevention
• Older people and vulnerable groups
• Wirral Integrated Care at Home
• Local area agreements (Social Services)

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Medication Review Referral Process
Referral will be directed to either
Obtain consent and fill in referral form

Identify patients who would benefit from review
MUR
or
CMR
Falls Understanding meds Discharge
Incorrect use of meds Side Effects
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Medication Review Referral Process
Community Pharmacy Medicines Use Review MUR A
review of HOW the medications are used without
sight of the clinical record by a community
pharmacist
Clinical Medication Review CMR A comprehensive
review of medication with sight of the clinical
notes by practice-based pharmacy staff
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Progress to Date
LAB
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Referrer to Date
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Outcomes to Date
Cost Reduction 5
Quality Improvement
Circa 14k
75
20

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Outcomes Oct 08 March 09
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GP Acceptance of Interventions Oct 08 Mar 09
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Case Study
Patient Details          Male 81yrs Referred
by               Popin Advisor Reason For
Referral Non compliance/ lack of understanding

• Current Medication   
• Atenolol 50mg 1 daily
• Bendroflumethiazide 2.5mg 1 daily
• Candesartan 8mg 1 daily
• Remdeine Forte 2 four times a day
• Arthrotec 50mg 1 twice daily                
• Simvastatin 20mg 1 at night
• Dromadol SR 200mg twice daily
• Algesal Cream as directed
• Quinine Sulphate 300mg 1 at night
• Amitriptyline 25mg 1 at night
• Diazepam 2mg 1 at night
• Problems Dislikes and therefore does
• not take diazepam, simvastatin, amitriptyline or
  dromadol
• As a result, patient had excess of medication at
  home

• Solution
• Removed excess
• 900ml Oramorph Soln (approx 15)
• 110 Dromadol SR 100mg Caps (approx 30)
• 145 Tramadol SR 200mg Tabs (approx 70)
• 2 bottles Amitriptyline 25mg Tabs (approx 2)
• 56 Simvastatin 20mg Tabs (approx 1)
• 20 Diazepam 2mg Tabs (approx 1)
•  
• Following discussion with his GP, arthrotec and
  algesal were also stopped
• Medication List Following Review
• Atenolol 50mg 1 daily
• Bendroflumethiazide 2.5mg 1 daily
• Candesartan 8mg 1 daily
• Remedeine Forte 2 four times a day
• Quinine Sulphate 300mg 1 at night

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Commissioning For Integrated Medicines Management
(CIMM)
Leading Across Boundaries RPSGB
NPC
Falls Prevention
Medication Review Referral
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Networks
LPC
LMC
Individuals Eg GPs Matrons
Medication Review Referrals
Social Services
PEC
Hospital Trust
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Next steps

• MURs / Criminal Record Bureau checks
• Demand / monitoring
• Target staff teams who work with at risk groups
• Sheltered accommodation
• Renal specialty nurses
• Post discharge MURs via Hospital pharmacists
• Care Homes
• Fire Service and Voluntary Sector

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Commissioning For Integrated Medicines Management
(CIMM) NPC
Leading Across Boundaries RPSGB
Medication Review Referral
Falls Prevention
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At risk of falls and have osteoporosis?
At risk of falls?
At greater risk of fracture
At risk of fracture
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Effect on the person

• In a year approx one third of over 65s
• will have a fall and approx half of over 80s
• 20 of those who fall are injured and up to half
  of those who fall (up to 10) sustain a fracture
• 40 of care home admissions are as a result of
  hip fracture
• About 50 of residents in care homes will have a
  fall 40 will have multiple falls
• One in five older people who suffer a hip
  fracture will die within 6 months

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Local statistics and costs

• Non-elective admissions to Hospital 07/08 due to
  fractures
• Fractured neck of femur - 203 patients cost
  1,348,944
• (cost/pt 6,645)
• Fractured wrist (Colles) - 121 patients cost
  304,197
• (cost/pt 2,514)
• NW Ambulance Service attendances due to falls
  Quarter 2 07/08
• Total number of fallers over 65
  1107
• Number of fallers who did not attend Hospital
  523 (47)

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Example Interventions for Falls Prevention
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Medication Review Referrals by Source January to
May 2009
Other Falls Referrals
Falls Team
All Other Referral Types
Total 28 Falls Referrals
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What Patients Say . . .

• 96 understood more about their medicines after
  the review
• 94 would recommend the service to someone else
  having difficulty with their medicines
• 96 rated the service as very good or good

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What Patients Say . . .

• The more you tell patients the better it is  -
• service could be advertised in the surgery
• We were glad to talk about medicines
• and how they affect us
• Was very pleased with the treatment XXX gave
  us, she explained everything . . . felt a lot
  better about my mums medication
• Nice to feel we are being
• cared for in later years thank you

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• Ewen.sim_at_nhs.net
• Jasmeen.islam_at_wirral.nhs.uk