Identifying high-risk patients and preventing readmissions. Nina Barnett, Krupa Dave, Sunaina Kaher, Paresh Parmar and Christine Ward September 2015

Transcription

1 Identifying high-risk patients and preventing readmissions Nina Barnett, Krupa Dave, Sunaina Kaher, Paresh Parmar and Christine Ward September 2015

2 What I will cover Background to readmissions. What is currently happening? What did we do? What did we find? Ways forward..

3 A bit about the team Long history of focus on older people Collaboration across interfaces of care Sustained services through changes

4 What do we know about readmissions? Admissions and readmission -??? Evidence of a problem in the UK

5 Who is at risk? Older people because Complex medical conditions Social vulnerability Transitions of care People with multimorbidity of any age Respiratory Cardiovascular

6 How do you address readmissions? Challenges of data collection Identifying patients Prediction tools Resources to manage identified patients LNWH data Newcastle hospitals

7 What about drugs? What is high risk medicine US data UK papers Number of drugs? MDS, discharge planning, communication with health professionals, organisations, staff, patients and carers..

8 What about the LNWH service History NSF, PCTs and acute trusts Developments in care of older people the multidisciplinary team Integrated Medicines Management Service

9 So, how does the service work? PREVENT guidance (identification) Integrated medicines management services, Scullin et al 2007 (process) Health coaching (patient centred care) Scullin C, Scott MG, Hogg A, McElnay JC. An innovative approach to integrated medicines management. J Eval Clin Pract Oct;13(5): Barnett N, Athwal D and Rosenbloom K. Medicines-related admissions: You can identify patients to stop that happening. The Pharmaceutical Journal. 1 April [assessed 11/08/2015]

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11 What exactly do we do? Medicines reconciliation Medicine review of long term and new medicines Patient centred medicines consultations, including discussion of newly prescribed, stopped and changed medicines Full documentation of medicines changes Documentation monitoring required on the discharge notification sent to GPs (an electronic process commenced in 2013)

12 What exactly do we do? Medicines discharge planning with patients, carers, health and social care teams in primary and secondary care to support safe and effective transfer of medicines related care. This can include medicines compliance aid assessment if required Communication and documentation of agreed actions with health and social care in secondary care regarding on-going care Pre-discharge referral to primary care health and social care professionals as well as carers where necessary to ensure continuity of pharmaceutical care. This can include referral to community pharmacists for the New Medicines Service or discharge Medicines Use Review where appropriate Post discharge telephone follow-up with patient and / or carers to support medicines related care identify on-going issues for referral and management before discharge from the service

13 Steps to address reducing preventable medicines related readmission Medicines reconciliation Person centred education Shared decision making Follow up in community pharmacy settings

14 How did we know this was useful? Comparison of two sites within LWNH 744 patients at NPH site (oct 2008-oct 2014) 92 patients at CMH site (Feb to oct 2014) CMH used PREVENT checklist to identify patients and then provided usual care Compared 30 day readmission data for PREVENTABLE MEDICINES RELATED READMISSIONS (PMRRs)

15 Results - Readmissions Original submission 589 patients at active NPH site ( ) were compared with 92 at control CMH site (2014) Updated data: 744 NPH patients seen readmissions (30d), 2preventable &medicines related (0.3%) 92 CMH patient seen readmissions (30d), 4 preventable& medicines related (4.4%). The difference was statistically significant (P=0.002). 3 saving for every 1 spent on the service (data peer reviewed)

16 Reasons for readmission NPH site

17 Reasons for readmission CMH site

18 Reasons for referrals hospital A = NPH hospital B = CMH

19 Interventions (NPH site)

20 Cost Provision of one wte pharmacist with consultant support for one year Time to undertake IMMS per pt Number of readmissions prevented For every 1 spent on pharmacist, over 3 saved

21 Case examples Mrs P Dementia Warfarin Mr A Recent stroke No previous medication

22 Learning from readmissions NPH site Dexamethasone patient CMH site Patient with dementia readmitted with seizures Laxatives

23 Findings in line with other centres Newcastle N Ireland Europe Learning from the work Costs saved were less as primary care not included Savings of 5-8 per 1 spent in other studies

24 Medicines adherence Interventions Compliance aid consultations (coaching approach) Cross sector communication Evidence to support importance of this Multidisciplinary working Post discharge communication and support

25 Limitations/Bias Admissions vs readmission Preventable? Medicines related? Standardisation of service Effect of PREVENT on CMH service External validation of PREVENT

26 Sustainability and roll out Sustained at LNWH since 2008 IMMS sites Ireland, Sweden, Norway Netherlands, process and savings demonstrated Local trust rollout with evidence to invest CLAHRC NW London Watford, Cardiff, Scunthorpe Presentations and publication 2011, 2015

27 Summary This is an innovative patient centred service which optimises safe and effective use of medicines Value: demonstrating a cost effective, high quality clinical service to help patients get the most out of their medicines safely Improvement: interdisciplinary and cross sector working and optimisation of skill mix A realistic prospect of rollout which will continue to reduce costs across the health economy