| In 2003, the intermediate care team in East Leeds told East
Leeds Primary Care Trust that it was spending too much time sorting out
patients’ medicines.
Focus group work with social services showed similar problems. So the
PCT, the intermediate care team and social services got together and
created a one-year project to tackle the problem.
The overall aim of the project is to improve medicines management services
for older people in Leeds. It has two strands: tackling issues in intermediate
care and also in social services. Two part-time pharmacists have been
employed to run the project: Claire Standage and Gillian Hunter. Together,
their roles equate to one-and-two-thirds times a full-time position.
Intermediate care team
The intermediate care team comprises nurses, occupational therapists,
a physiotherapist and clinical support workers.
Altogether, the team has about 45 patients on its books at any one
time. Roughly 70 per cent of the patients are referred to the team
on discharge
from hospital. The problems
that patients face on discharge are well-documented — patients
cannot cope with new medicines at homes, they do not know what to do
with large stocks of old medicines at home
and repeat prescription records at surgeries do not tally with the new
medicines — so it is clear why they need the help of the intermediate
care team. But the team tackles a lot more than medicines; it takes a
holistic approach to rehabilitating a patient after a stay in hospital.
The remaining 30 per cent of the team’s workload are patients referred
from community practitioners such as GPs and district nurses. “They
tend to be people who have had a fall or a stroke and need a short burst
of rehabilitation intervention until they become stable enough to continue
on their own,” Miss Standage explains.
“Intermediate care is an ideal place for pharmacists to work,” she
says. “Every time I go to see a patient I make some sort of intervention,
even if it is something relatively basic such as ordering easy-open container
tops.” Needs assessment
When a patient is first referred to the intermediate care team, a member
of the team visits the patient at home and carries out a needs assessment.
As part of this assessment, a standardised form has been introduced
to identify problems with medicines. This first, basic medication review
is then given to the pharmacists who use it to prioritise the order
in which they will visit patients for a more in-depth look at their
medicines.
The basic review covers practical issues around supply and administration
of medicines, including how repeat medicines are obtained and whether
the patient needs help to take their medicines. “One of the biggest
problems is that medicines are about to run out and patients don’t
know how to deal with repeat prescriptions, particularly when their medicines
have been changed. So we will see these patients before their current
supply runs out,” explains Miss Standage.
Once patients have been prioritised, one of the pharmacists then carries
out a more detailed medication review. A first visit takes between 45
and 60 minutes per patient. Shorter follow-up visits are also carried
out. “In the review, we try to get a picture of the patient’s
daily routine and how medicines fit into it,” explains Miss Standage. “It
has been designed so we don’t duplicate the questions asked in
the first
assessment.”
Again, the review is based on a structured questionnaire. It begins by
listing all the medicines the patient takes, including over-the-counter
and herbal preparations. It also lists any medicines on the patient’s
repeat prescription list that are currently not being taken and the reason
for not being taken. It then goes on to cover the questions listed in
Panel 1.
Panel 1: Review questions
After taking a full medication history, the questions asked during
the medication review are:
· Do you ever have problems obtaining your medicines or ordering
repeat prescriptions?
· Does anyone help you with your medicines at home? If so, who
and what do they do to help?
· Some people forget to take their medicines from time to time.
Do you? What do you do to help remember?
· Some people take more or less of their medicines, depending on
how they feel. How often does that happen to you?
· Most medicines have side effects. Do you have any?
· Do you have problems getting medicines out of boxes and bottles?
· Do you have problems reading your medicine labels?
· Any other problems? |
On average, the pharmacists review 35 patients a month. “Our role
is to make a judgement on how the patient will manage with their medicines
and work out what help they need to improve the situation. We try to
take a concordant approach whenever possible.”
There is nothing new about the interventions the pharmacists make: they
are common sense. Examples include rationalising medicines so patients
take the fewest number of doses possible, recommending easy-opening container
tops, putting reminder stickers on the refrigerator or cooker, suggesting
the
patient keeps their tablets beside their bed and involving the family
in prompting
medicine-taking. They also tackle issues like hoarding medicines and
might make referrals to home carers or social services if appropriate. “The
majority of problems I identify
are with adherence to the regimen,” she
comments.
Some interventions are less obvious. For example, home carers tend to
visit only in the mornings or early afternoons. If patients rely on home
carers to help them take their medicine then those medicines prescribed
at night simply will not be taken. “So whenever possible we switch
evening doses to the morning, even for things like statins. In an ideal
world we wouldn’t have to do this but it is better for them to
be taken in the mornings than not at all.”
Another example is with compliance aids. “If patients are given
something separately to their compliance aid, they may not take it. So
we work with the community pharmacists to put everything into the aid,” Miss
Standage says. “You have to take a flexible approach. We would
never compromise a clinical decision but you have to be practical and
consider how a patient is taking their medicines.”
Her experience of reviewing patients’ medicines at their homes
makes Miss Standage think that it is the optimal place for reviews to
take place. “It is only there that you get a real feel for how
they cope with their medicines. You can understand their daily routine
and work out what help they need. If the home is in complete chaos, they
are probably not taking their medicines properly.”
Following the review, the pharmacists speak to the GPs to discuss interventions
and update the patients’ repeat prescription record. The GPs will
make changes to prescriptions when needed.
One of the problems often encountered with the repeat prescription systems
at the GP surgeries is that no one person takes responsibility for ensuring
that repeat records are updated, she explains. This can lead to a long
list of medicines on the repeat, many of which should no longer be taken,
so it is easy for the wrong ones to be prescribed. “There is a
potential role for pharmacists to help solve this, working across a number
of GP surgeries.”
Miss Standage also involves community pharmacists. “After a review,
I often go to see the patient’s community pharmacist to explain
what I have done and to ask for their help with certain things, for example
ensuring the patient receives large-print labels,” she says. “Sometimes
I feel like I am treading on community pharmacists’ toes. After
all, they are the ones who have known the patient for years. The only
reason it is me doing the reviews and not them is because I have got
the time to carry out home visits.”
She adds that the majority of community pharmacists would like to get
involved in this type of work but that the current pharmacy contract
is holding them back. She has high hopes that the new contract will solve
this. “For instance, if a GP prescribes an evening dose for a patient
who we have changed to having all their medicines in the morning, the
community pharmacist should be flagging this up to the GP.”
The two intermediate care pharmacists then review the patients after
three months. The follow-up visits are an essential part of the service. “I
feel strongly that teaching someone about how to manage their medicines
is an ongoing process. We can’t just visit someone once and expect
everything to be perfect after that. It can be a steep learning curve
at first,” Miss Standage comments. Social services
The second part of the one-year project involves social services. Once
the medication reviews in intermediate care had been established Miss
Standage, while still undertaking some of the reviews, started to tackle
medicines management in social services and look at strategic issues.
The bulk of the reviews in intermediate care are now carried out by
Ms Hunter.
“I started by shadowing social service home care employees to find
out how they deal with medicines,” explains Miss Standage. “Before,
I thought that they just prompted the patient to take their medicines
but it is actually much more hands-on than that. For example, they pop
the tablets out of blister packs for patients.”
It is also social services staff who are carrying out the Single Assessment
Process (SAP) in Leeds. “If medicines problems are identified,
the assessors simply do not know how to deal with them or who to refer
problems to,” Miss Standage explains. “So often, their only
way of helping is to organise a compliance aid and home help staff to
prompt the patient.” This takes the responsibility away from patients. “Compliance
aids should be a last resort. They take patients’ independence
away so patients don’t know what their medicines are any more.
Before introducing one, bigger-print labels, medicines charts and prompting
by family and home care staff should all be tried,” she comments.
This demonstrated exactly how much a pharmacist’s input was needed
in the SAP. “In an ideal world, the SAP assessor could contact
the community pharmacist for advice about how to deal with medicine-related
problems but, at the moment, they are referring patients to me.” She
adds that being this point of reference is something that all pharmacists
could consider.
Another problem is that medicines fit into every aspect of a patient’s
care. “The GP prescribes, the community pharmacist dispenses, the
district nurse and social services assist... no-one has sole responsibility
and everyone assumes it is someone else’s job. This is why, quite
often, things go wrong,” Miss Standage says.
Having studied the local situation, Miss Standage reported her findings
to the East Leeds area home care manager and the resource manager of
the community support service at social services. “This is where
it gets really exciting,” she says. “I presented the results
at a meeting of the group responsible for implementing the medicines
section of the National Service Framework for Older People in Leeds.” Some
of the issues she highlighted are listed in Panel 2.
Panel 2: Current problems
Some of the issues highlighted as being wrong with the current
system of medicines supply are:
· The current social services medicines administration system
is not used consistently and documentation is variable
· Problems with compliance aids
· There is no standard way of handling medicines by home care staff
· Many different agencies are involved with medicines but there
is no awareness of roles and responsibilities
· Hoarding of medicines, particularly laxatives and analgesics
· The large incidence of non-compliance with medication |
At the meeting, it was decided that a
medication policy subgroup should be established. Where this new group
is different is that its members include sheltered housing wardens and
independent care home staff, along with GPs, community pharmacists, district
nurses, social services and home carers. “The group aims to improve
medicines management for older people,” she says. “We will
be writing a medication administration policy that we want all the professions
to sign up to. It will clearly describe the roles and responsibilities
of all those involved.” The work is already progressing: the group
held its first meeting last week. The project’s future
The project is allowing data to be collected on whether a pharmacist
is needed in the intermediate care team. For the role to be funded
beyond the project year, its use has to be demonstrated. Miss Standage
is convinced that it will carry on, but perhaps based in primary care
rather than within the intermediate care team.
With the work that the medication policy group is carrying out, everyone
in health and social services will be involved in medicines management
in Leeds in the future. “A medication review can only give you
a snapshot of the patient’s life. Sometimes a patient can be quite
lucid and you decide that everything is fine, only to be told by the
home carer that the patient has dementia and will have forgotten everything
you have said an hour later. So it is crucial that everyone is
involved to achieve a sustainable intervention,” she says.
Sustaining the intervention is what it is all about. “Medicines
regimens are fragile and need to be protected. They can be stable and
working fine and then something happens, like a GP prescribes a new drug
at a different time, and suddenly the whole regimen is blown apart,” Miss
Standage says.
Pharmacists are a key element of keeping the fragile structure sealed
together by providing an ongoing medicines management service. |
The
Pharmaceutical Journal