Care Home Support Service Review and Medicines Optimisation

Transcription

1 Community Pharmacy Wales A Community Pharmacy Enhanced Service Template Care Home Support Service Review and Medicines Optimisation Date April P a g e

2 Care Home Support Service Review and Medicines Optimisation Background In her 2014 report A Place to Call Home? the Older Person s commissioner for Wales concluded that too often, there is an acceptance by organisations and the system of an overall level of care that is simply not good enough. Much of what is now considered to be acceptable should be considered unacceptable in 21st century Wales and falls below the standard that older people have a right to expect. The report identifies the importance of patient centred care which underpins this service. In addition the service incorporates the relevant aspects of the 2014 Trusted to Care review. Growing concern around medicines in care homes is being driven by concern over unacceptably high error rates, and growing awareness of potential overprescribing and waste. These are important aspects of the Prudent Healthcare policy in Wales, which identifies care homes and transitional care as key elements of the healthcare strategy for Wales Too often the management of medicines in care homes contributes to the unacceptable care provided to residents of care homes. The care homes use of medicines (CHUMS) study observed that errors occur on 8.4% of medication administration events. That would mean that a care home resident being administered medication three times a day would be 99.9% certain to receive at least one medication administration error every month. A UK evaluation of a barcode medication management system in long term residential care (Szczepura, Wild and Nelson, 2010 & 2011) identified 6 7 medication administration events per resident per day with around 2 errors prevented by the system per resident per month. The most common error was giving medication at the wrong time although, over a three month period over one half of residents (52%) were exposed to an attempt to give medication to the wrong resident. Back in 2006 the National Service Framework for Older People in Wales 2 highlighted the problem of medication administration errors stating, administration errors especially non-administration occur relatively frequently both in hospital and care settings (page 165). Care home residents should theoretically be protected from medication administration errors under The Care Homes (Wales) Regulations (2002) 3 which state, The registered person shall make arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. In addition the Governments in Wales and England have introduced minimum standards which must be met by care home providers. Despite many reports highlighting the issues of medicines management in care homes it remains problematic. According to a report by the Care 2 P a g e

3 Quality Commission 30% care homes for older people in England are failing to meet the minimum standards required for the management of medicines. The Care and Social Services Inspectorate Wales annual report also identified medication management as an area needing attention and reported that their inspectors had placed requirements for action in relation to medication at almost a third (32%) of care homes. The skills and expertise of community pharmacists and their teams as the experts in medicines have much to contribute to the optimisation of medicines use in care homes and supporting the reduction of waste. In drawing up this template service CPW has consulted with a number of stakeholders including those involved in managing care homes, providing medicines management services to care homes, regulating and inspecting the care home sector, commissioning care home services and in providing medicines management support to care homes. This template incorporates the feedback from stakeholders and seeks to deliver the requirements of NICE Guidelines on managing medicines in care homes. The template service starts with the resident and their needs for pharmaceutical care and is built on the foundation of safe and efficient supply, supported by an appropriate level of clinical intervention. The service is also built the Prudent Healthcare principles and in particular remodelling the relationship between the user and provider on the basis of co-production. 3 P a g e

4 Feedback from key stakeholders Feedback from key stakeholders indicated the following:- The move to outcomes focussed inspections by CSSIW has meant that there are less frequent in depth reviews of medicines management processes. The need to ensure that the service is cost effective through the appropriate use of skill mix. A basic review of medication management policies and procedures. (e.g. ordering processes, CD management, stock control etc) to be done at least annually. Observation of a drug administration round (as part of above, or separately) re the Trusted to Care report Reconciliation and review of medication for all new patients transferred into the home or discharged back into it from hospital Medicines management support of people coming to the home for a period of respite. A medicines reconciliation exercise to ensure pharmacy records, MARs and repeat prescription details are in alignment. Monitoring and provision of guidance/education on key therapeutic issues e.g. AKI, inhaler technique, pain management in dementia, SMBG testing, use of nutritional supplements, use of antipsychotics etc. Could be achieved on an annual rolling program. Identification of patients with problematic poly-pharmacy, with the application of STOPP/START tools and a clinical review of patient medication in conjunction with GP or GP medical records. A robust SLA which clearly sets out the agreed services and support offered by the Pharmacy. Support and guidance in the development of medication policy aligned to NICE guidance and best practices Access to pharmacy support on an as required basis. The appointment of dedicated / named Pharmacist for each care home Medication / clinical reviews in collaboration with GPs for identified problem residents. Provision of audits and analysis of trends and prescribing patterns to allow improved governance and sustained improvement to resident outcomes e.g. inappropriate prescribing of antibiotics and nutritional supplements Provision of ongoing staff training to reduce staff turnover and to meet the changing needs/demands of residents and to ensure policies, best practices and adherence to legal and regulatory requirements are upheld to avoid embargos, escalating concerns etc. which otherwise has a detrimental commercial impact on the home owner Delivery schedules and cut off times agreed to meet the needs for interim and emergency prescriptions A transparent and fair escalation and concerns mechanism for prompt resolution of complaints / dispensing errors etc. Any service should not be limited to providing support for care homes for older people as there are medication management needs in other establishments such as mental health and children s homes. 4 P a g e

5 A review of covert medicine administration policies should be part of the service. Similarly the approach to the use of homely medicines and self-administration of medicines should be similarly looked at. Acknowledgement: CPW would like to acknowledge the support provided by John Dicomidis, Pharmacist, Complex Care Team at the Aneurin Bevan University Health Board with the design of this service. 5 P a g e

6 The format of the service Taking into account the feedback from key stakeholders and also the need to contain the cost of delivery through the utilisation of skill mix a service with three elements has been designed. This approach ensures that Health Boards have the flexibility they require in terms of service commissioning while providing a degree of consistency of approach across Wales. The service encourages collaborative partnership working with GP practices for the benefit of patients. Element 1 The provision of a systematic review of all medicines management processes in the care home. The review has the objective of supporting the home to meet NICE guidelines (SC1) and all aspects of the management of medicines including ordering, check in of deliveries, storage of medicines, administration of medicines and record keeping are reviewed. As this element of the service is administrative in nature it can be provided by either a pharmacist or a suitably trained technician. To balance the need for regular support with the cost of commissioning the support will be provided on a 4-monthly cycle. In recognition of the need to check some aspects on a frequent basis while other elements only require an annual check a Medication Audit Tool for Implementing NICE guidelines in Care Homes checklist has been designed identifying the frequency of review. Element 2 This element of the service utilises the clinical skills and knowledge of the pharmacist in optimising the use of medicines and in meeting the needs of more complex residents. In addition it is recognised that Health Boards will want to audit defined aspects of medicines usage such as the use of antipsychotics or the covert use of medicines. Element 2 contains the following elements: 1. A review of medicines with residents who take a large number of medicines. 2. A medication review for all new residents to the home. 3. A medication review of residents with more complex drug regimes identified by the home manager. The review will incorporate a STOPP/START approach. 4. Medication support where required for residents admitted for respite care and who have more complex medicine regimens. 5. A Health Board directed medication clinical audit. 6. A named pharmacy contractor for the care home to receive advice between visits. This element of the service is again provided on a three visits per annum, at an approximately four-monthly frequency, basis. While the Health Board will commission this as a standalone service, the pharmacy will utilise the MUR and DMR elements of the community pharmacy 6 P a g e

7 contractual framework to support some elements of service delivery where this is appropriate. Element 3 It has been suggested by some of the stakeholders that there would be benefit in providing educational support to care home staff. This may range from training new care home staff, through periodic update training to more specialised training requirements as identified by care home managers. It is also recognised that a number of pharmacies provide this element as part of their care home supply arrangements. Some care homes may wish to commission this on a private funding arrangement however feedback from Health Boards indicates that in some targeted cases they may see value in commissioning training for care home staff. This third element has been included for completeness such that commissioners have the option to include this element as part of the commissioning package where they feel it is appropriate. 7 P a g e

8 Service Specifications How to use this template This document is intended as the basis from which the Health Board should produce its Service Level Agreement, and as such the elements within can be tailored to Health Board needs. Health Boards should give due regard to the National Health Service (Pharmaceutical Services) (Remuneration for Persons providing Pharmaceutical Services) (Amendment) (Wales) Regulations 2007 and the statutory obligations these regulations place on Health Boards to consult the relevant Community Pharmacy Wales Regional Committee on issues of remuneration for local Enhanced Services. INTERPRETATION In this document: Pharmacist means a registered pharmacist, or any person providing any part of the service on behalf of a pharmacist, provided that it is legal for them to do so; Pharmacy means any premises where drugs are provided by a pharmacist as part of pharmaceutical services; Pharmacy contractor (or contractor) means a person lawfully conducting a retail pharmacy business. Registered Pharmacist means a person who is registered in Part 1 of the GPhC register or in the register maintained under Articles 6 and 9 of the Pharmacy (Northern Ireland) Order 1976; Registered Pharmacy Technician means a person who is registered in Part 2 of the GPhC register. Definition of Care Home The Definition of a Care Home is outlined in the Care Standards Act This abolished the distinction between nursing and residential homes under the term Care Home. This states: 3.(1) For the purposes of this Act, an establishment is a care home if it provides accommodation, together with nursing or personal care, for any of the following persons. They are- a) persons who are ill or have been ill b) persons who have or have had a mental disorder c) persons who are disabled or infirm d) persons who are or have been dependant on alcohol or drugs But an establishment is not a care home if it is- 8 P a g e

9 a) a hospital b) an independent clinic c) a children s home or if it is of a description excepted by regulations. 121 (9) - An establishment is not a care home for the purposes of this Act unless the care, which it provides, includes assistance with bodily functions where such assistance is required. This includes both short-term and long-term residents Despite not being included in the official definition of a care home, the Health Board may however still wish to commission the service for mental health units and children s homes. 9 P a g e

10 Service Specification for Element 1 Care Home (support and advice on storage, supply and administration of drugs and appliances) 1. Service description 1.1 The contracted pharmacy will provide advice and support to the staff within the care home, over and above the Dispensing Essential service, to support the proper and effective ordering of drugs and appliances, their safe storage, supply and administration and proper record keeping. 1.2 The service will apply to all medication within the care home irrespective of the supplying pharmacy. 1.3 The pharmacy will advise the care home on the establishment of appropriate systems to facilitate the sharing of information about the person s medicines when they move from one care environment to another; and 1.4 The pharmacy will provide the home with a report after each visit containing recommendations for improvement if required. 1.5 The pharmacy will accompany a drug administration round as part of its review where appropriate or accompany elements of patient centred care that occur during the visit period. 1.6 The pharmacy will provide the home with details of a relevant named contact for routine inquiries and medication advice. 1.7 The pharmacy will support the home in implementing NICE guidelines. 2. Aims and intended service outcomes 2.1 To support the effective management of medication and reduce administration errors within the care home, through regular review of medication management systems and processes. 2.2 To promote patient safety within the care home through improved medicines handling with a particular focus on: ordering, storage, administration and disposal of medicines and appliances and use of residents own medicines (prescribed and purchased). 2.3 To provide support and advice to on appropriate record keeping procedures. 10 P a g e

11 2.4 To review all medicines handling processes within the home against NICE guidance and national minimum standards, together with other appropriate guidance. 2.5 To provide advice to the home and to assist in improving medicines handling processes. 2.6 To support the care home in meeting the standards required by CSSIW. 2.7 To support reduction in medicines wastage within the care home. 3. Suggested Quality Indicators 3.1 The routine visits by the care home inspection organisation do not highlight any major shortfalls in the systems for the management of storage, supply, administration and disposal of medicines that have not been previously brought to the attention of the home. 3.2 The pharmacy reviews its standard operating procedures and the operation of the service on a bi-annual basis. 3.3 The pharmacy can demonstrate that pharmacists and staff involved in the provision of the service have undertaken CPD relevant to this service. 3.4 The pharmacy participates in an annual Health Board organised review of service provision. 3.5 The pharmacy co-operates with any locally agreed Health Board - led assessment of service user experience. 11 P a g e

12 Service Specification for Element 2 Care Home (medicines optimisation and clinical support) 1. Service description 1.1 A named pharmacy provides clinical advice and support to the staff within the care home during the visit and will also provide clinical advice when required outside of planned visits during normal opening hours of the pharmacy. 1.2 This part of the service will be undertaken by a pharmacist with the clinical skills required to complete the medication reviews and clinical audits required. 1.3 The pharmacist will accompany a drug administration round, or part of a patient centred medication process as part of the visit at least once per annum. 1.4 The Pharmacist will ensure that they are aware of any medicines related issues which were raised at the most recent care home inspection organisation visit to the home if this is provided by the care home. 1.5 The pharmacist will provide support and liaise as necessary to support the synchronisation of prescribed medicines. 1.6 The pharmacist will provide advice on appropriate adherence support for residents self administering medicines. 1.7 The pharmacist will liaise with the GP and other healthcare professionals as appropriate to seek to resolve issues identified on the visit. 1.8 The pharmacist will undertake a Medicines Use Review (MUR) and a Polypharmacy and Medicines Optimisation Review (guidance provided) incorporating STOPP/START principles, on priority residents as identified by the GP or Care Home Manager. This would normally include those residents who are prescribed large numbers of medicines or who have been identified by the care home as target residents. 1.9 The pharmacist will undertake a Discharge Medicines Review for all residents newly admitted to the home. The review will be undertaken within four weeks of admission and may necessitate an additional visit to the home The pharmacist will undertake a Discharge Medicines Review on request for residents admitted for respite care. 12 P a g e

13 1.11 The Pharmacist will undertake one Health Board directed clinical audit on each visit to the home if required by the Health Board. The clinical audit requirements would be such that the clinical audit could be completed within the visit time. Examples of potential clinical audits include: As Directed and PRN Medication Covert administration of medicines. Diabetes Management Falls assessment Protocols to manage common conditions Inhaler usage PRN medication NSAID audit Pain management review Therapeutic drug monitoring Copies of potential clinical audits will be published on the CPW website 1.12 The pharmacist providing the service will keep a record of cost savings, prescribing recommendations to the GP and medication errors of clinical significance 1.13 The pharmacist will provide the home with a report of issues identified, recommendations and actions undertaken. Where relevant the pharmacist will provide a copy of the report to the supplying pharmacy and the relevant GP practice The pharmacist will provide a record to the Health Board link pharmacist if requested to do so The pharmacy will use specific Health Board paperwork for documenting information if requested to do so The pharmacist will provide the home with a named contact for the care home to receive advice between visits. 2. Aims of the service 2.1 To provide clinical advice and support to the home. 2.2 To improve resident outcomes and medicines safety through improved prescribing and compliance. 2.3 To provide pharmaceutical care and advice to identified residents in the home and to care home staff. 2.4 To support transfers of care by ensuring appropriate systems are in place to facilitate the sharing of information about the person s medicines when they move from one care environment to another. 13 P a g e

14 2.5 In partnership with the GP to review prescribing for identified residents. 2.6 To undertake identified clinical to improve prescribing and to reduce waste in collaboration with the GP. Background information that may be helpful to pharmacists providing the service. NICE Guidelines Managing Medicines in Care Homes March Improving pharmaceutical care in care homes, which can be accessed at: Royal Pharmaceutical Society. Pharmacists Improving Care in Care Homes. September Available at: Recommendations and policy statements on the role of pharmacists in care homes. All Wales Medicines Strategy Group. Polypharmacy: Guidance for Prescribing in Frail Adults. July Available at: %20Guidance%20for%20Prescribing%20in%20Frail%20Adults.pdf The Health Foundation. Learning report: Making care safer. June Available at: %20learning%20report.pdf?realName=WIpgJD.pdf Transfer of care guidance RPS: Keeping patients safe during transfers of care: The handling of medicines in social care: 14 P a g e

15 Additional educational support available from WCPPE or in development Polypharmacy e-learning module. Face to face events on medicine in the elderly Therapeutic updates on a range of clinical conditions Communication skills programme. Face to face events on professional accountability for the care of the elderly and vulnerable Chronic conditions management programme- this is a suite of resources. 15 P a g e

16 Service Specification for Element 3 Care Home (educational support for care home staff) 1.0 Service description 1.1 The purpose of this element of the service is to provide care home staff with the underlying skills and knowledge to support them in improving their knowledge of medicines and medicines administration. 1.2 The pharmacist and technician will be responsible for the provision of training for care staff on medicines issues, on an opportunistic basis during regular visits. In addition and if commissioned by the Health Board or Care Home the pharmacy is able to provide the following elements:- 1.3 In discussion with the care home manager the pharmacy will provide training to seek to improve the skills of the care home staff, including ordering, storage, administration, disposal and record keeping of medicines. 1.4 The pharmacy will support a consistent skill set in the home by reviewing training needs with the owner and provide support in meeting identified training needs. 1.5 Further, and more advanced training on the administration of medicines could be provided in consultation with CPW. 16 P a g e

17 Template Service Level Agreement 1 The home should be located within the boundaries of the Health Board and registered under the provisions of the Care Standards Act 2000 to provide residential or nursing care to residents of the home. 2 A pharmacy wishing to provide this service will need to apply to the Health Board. 3 There will be one contract only for support and advice to a particular home in place at any given time. 4 It is recommended that the service is provided by the pharmacy supplying the Care Home with medicines. This would allow for the pharmacy to build on an existing relationship with the home, and take a greater role in supporting the residents and carers in using medicines safely and effectively and encouraging best practice. If the regular pharmacy is not able to provide the service it can be provided from another community pharmacy. 5 Although fees will be reviewed annually the contractual relationship will be of a permanent nature and will automatically roll over from year to year provided the Health Board and the care home are happy with the service provided. Either party can terminate the agreement by giving the other party 90 days written notice. In the event of termination of the service, the party terminating the service will ensure a minimum of 90 days notice of termination of the scheme is provided to residents receiving the service. 6 Only those pharmacies commissioned by the Health Board to provide a Care Home Service will be eligible to receive payments under this scheme. 7 The Health Board, or their authorised officer, shall determine the fees and allowances payable in respect of the service in consultation with Community Pharmacy Wales. 8 The Health Board will enter into a Service Level Agreement (SLA) with all pharmacies commissioned to provide the service. 9 Any pharmacy entering into a contract with the Health Board to provide this service must complete and submit form PS/ES/5 CONTRACTOR LISTING. 10 The pharmacist/technician will ask to see physical evidence of the indicator being checked. 11 Payments for the service will be subject to nationally agreed post payment verification arrangements. 17 P a g e

18 12 The pharmacy should ensure that the following records are accurate; Medicines Administration Record (MAR) chart (or other written care home record of administration) The pharmacies Patient Medication Record (if possible) The surgery s prescribing record i.e. the copy of the repeat list on the right hand side of a recent WP10 prescription where this is available to the pharmacy. 13 Where Element 1 of the service is provided by a non-pharmacist a supervising pharmacist will be identified for advice and support. 14 A report will be provided to the care home following each visit of any advice given. Copies of the reports will be retained in the pharmacy and be available for inspection by the Health Board. A template for the report can be found on the CPW website. 15 For Element 1 of the service all areas covered on the Medication Review Tool for Implementing NICE guidelines in Care Homes will be reviewed at the required frequency and the date of the review will be recorded on the form. 16 For both Element 1 and Element 2, it is recommended that three visits will be undertaken each year at approximately 4-monthly intervals at a time convenient to the pharmacy and the care home. If the Health Board believes that 6-monthly visits are sufficient to meet the needs of the care home then the SLA can be adapted accordingly. 17 The pharmacy will complete three reviews/clinical audits throughout each year. The format of the clinical audit will be defined by the Health Board. 18 The pharmacy will ensure that they are aware of any medicines related issues which were raised at the most recent care home inspection visit to the home. 19 The pharmacy will advise the care home on the content of their medicines related policy documents, including the administration of medicines for acute conditions, use of homely remedies, self administration and procedures when there are alterations to residents medication regimens. 20 The Health Board will need to provide a framework for the recording of relevant service information for the purposes of review and the claiming of payment. 21 All pharmacy staff providing the service must have the necessary expertise and be familiar with NICE guidance. 18 P a g e

19 22 The contractor has a duty to ensure that pharmacists and staff involved in the provision of the service are aware of the requirements of the service specification. 23 All support staff shall be fully informed and suitably trained in relation to their involvement in the service which may include the provision of any part of the service provided on behalf of an approved service provider, provided that they are competent and it is legal for them to do so. For the purpose of this agreement, staff shall include any person or persons employed or engaged by the contractor, to provide any part of the service; 24 The contractor will ensure that appropriate indemnity arrangements are in place for all staff involved in the provision of the service. 25 The contractor will have appropriate arrangements in place to maintain service continuity and take all reasonable steps to ensure that residents are able to access this or equivalent services in the event of unforeseen closure of the pharmacy. 26 The Health Board will put arrangements in place for the pharmacy to exceed their annual MUR allowance if this required to support patients in the care home. The Polypharmacy and Medicines Optimisation Review is more specialised than the MUR advanced service and the MUR cannot be used to meet this requirement. 27 The contractor will notify the relevant Health Board, of circumstances which result in the temporary unavailability of the service for more than 14 calendar days. 28 The contractor will participate in any reasonable publicity of the availability of the service required by the Health Board. 29 The service provider will be mindful of their responsibilities in relation to the safeguarding of vulnerable adults and raise any concerns with the local safeguarding team. 2.0 Claiming for Payments 2.1 The fee payable to community pharmacies will be paid on submission of the relevant claim. Claims will be submitted via NECAF if this is supported by Welsh Government. 2.2 No patient, clinical, professional or other confidential details should be included in any reimbursement claim. 2.3 Fees will be paid as follows: 2.4 Fees for the provision of the service will be reviewed by the Health Board prior to January each year and the revised rates will be effective from the 1 st April. 19 P a g e