Medicines
Management
Issue no 4, p11-13
July/August 2002
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Medicines
Management |
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Features |
Community pharmacists can help make the best use of intermediate care
Berwick Infirmary is the most northerly community hospital in Northumbria Healthcare Trust and indeed is either the first or last (depending on your outlook) community hospital in England. We first started to look at the provision of clinical services to the community hospital by community pharmacists in collaboration with the community hospital pharmacy in 1994, primarily because of its remoteness from the local district general hospital in Ashington (63 miles). Traditionally community hospitals have been associated with the long-term care of elderly patients. However, as pressure has increased on DGHs to optimise their use of beds, the role of community hospitals has changed to providing what is now termed intermediate care: "A short period (normally no longer than six weeks) of intensive rehabilitation and treatment to enable patients to return home following hospitalisation, or to prevent admission to long term residential care; or intensive care at home to prevent unnecessary hospital admission." In addition, community hospitals no longer provide so much respite care but treat patients who are acutely ill but do not need to, or are unable to, travel to the DGH, such as those with acute exacerbations of COPD or worsening heart failure. The pressures on acute beds in DGHs has led to more acutely ill patients being transferred to community hospitals for rehabilitation. Patients are also assessed for admission to residential care when they cannot cope with their illnesses at home and there is also a role in providing day case surgery. Many of these patients, therefore, have chronic diseases with a high degree of associated morbidity, which can be manifest in frequent readmissions to hospital. If we are to make optimum use of beds in secondary care, we need to make efficient use of intermediate care beds. Directing pharmacy resources at caring for these patients can help minimise readmissions to hospital and allow this cohort of patients to live in the community for as long as possible before admission to nursing or residential care. (In the study we conducted, 40 per cent of the control group, excluding respite and planned readmissions, were readmitted to hospital within six months of discharge.) Developing the service A pilot study was set up in the summer of 1994 to test the feasibility of a community pharmacist-led service which provided discharge medication information for patients within the hospital. This service proved popular with both staff and patients and it became apparent that there was a role for community pharmacists in these units, regardless of the geographical factors that initially made us think about this model of service delivery. The initial pilot ran for six months, following which a bid was put tog-ether for a second study, which aimed to assess if there were any clinical benefits from the service. The specific measures we chose were unplanned readmission to hospital within six months of discharge and death within six months of discharge. Initial funding Funding was obtained partly from the DoH (Seizing the Opportunities fund) and partly from Northumberland Health. The study started in the summer of 1997 and ran for about a year. The intervention group comprised 89 patients and the control group 88. Results showed that patients with at least one readmission were reduced in the intervention group from 40 per cent to 30 per cent and corresponding mortality rates were reduced from 17 per cent to 11 per cent within the six-month post-discharge period. The service model that we developed included two elements. First the inpatient prescription was reviewed several days before discharge using a work-up of the medical and nursing notes. Any problems with treatment were taken up with either the duty GP or the visiting care of the elderly consultant, depending on the time-scale and the nature of the problem. These interventions were recorded and analysed. Information leaflet for patients Shortly before the patient was due for discharge a pharmacist produced an information leaflet for the patient which consisted of a "compliance grid" detailing what medicines would be prescribed on discharge, when they were to be taken and the general purpose of each medicine. This was followed by brief paragraphs of text on each medicine stating the potential benefits and possible side effects, especially cues for seeking further medical advice. The information leaflet was put together using a template for the grid and a database of files for each of the medicines used. We edited the standard drug files to suit the patients' medical conditions where necessary. To keep the information brief and relevant to each patient we kept the information disease specific. For example if a patient was prescribed a beta-blocker for hypertension, we did not include any information on angina. The leaflets were put together using a standard Word for Windows program by inserting the drug files into a template for each patient. The information leaflet formed the basis of a consultation with the patient to ensure that the patient knew what to take when they got home (and what not to take) and that they had an opportunity to discuss the risks and benefits of treatment with a pharmacist. The hypothesis that we were testing was that giving patients customised information on their discharge medication would reduce the mortality rate and readmission rate. A pragmatic design was used for the study and one of the two local community pharmacists providing the service visited the hospital wards three times a week. This was based on the amount of time available to the pharmacists and the expected length of stay for patients. Average visits took about two hours although this could be highly variable, depending on the number of patients. We intended to run the study as a randomised controlled trial, however, randomisation of the subjects was ultimately not possible because of issues surrounding enrolment and informed consent. Informed consent proved difficult Obtaining informed consent from patients for this type of intervention proved difficult in practice (a substantial minority — approximately 30 per cent declined). When the enrolling pharmacist explained the basis of the study, patients that tended to be interested in their medicines generally wanted to take part and those that were a little confused or uninterested in their medicines tended to decline their consent. Therefore those that gave their consent were unwilling to be control patients and actively sought information. This issue was further complicated by direct referrals that the nurses made to the visiting pharmacist. Because of this the randomisation broke down and the patients were then recruited sequentially, first the intervention group and then the control group. Other exclusions from study The other main difficulty arose because of the short notice given before discharge for some patients. This could be as little as one hour following an unscheduled visit from the GP. These patients were excluded from the study. Readmission to hospital was assessed from computerised admissions data. Planned readmission events, such as respite care, were excluded. The frequency of admission to hospital was recorded along with the duration of stay. This method could not identify unplanned admissions to other NHS trust hospitals, for which no records were available. Six-month follow-up Each patient was followed up to determine if they were still alive six months after their discharge date. Several patients had left the health authority catchment area within this time period. These individuals were traced to their new area and similarly assessed. All patients were followed up in this way. Results from this study indicate that patients discharged from a community hospital are highly likely to die within six months (17 per cent in the control group) and are frequently readmitted to hospital in the same period. This represents a high cost to both individuals and the health care system Impossible to secure funding Despite the evidence of potential benefits of pharmacist intervention and patient demand for the service, it has to date proved impossible to obtain recurring funding. Under current ways of working, releasing pharmacists from their pharmacies proves at best expensive and at worst impossible. This will remain the case until pharmacists are able to routinely leave their premises for short periods of time. There was no funding stream for pharmacists to tap into within primary care to pay for this type of service and secondary care seemed unwilling, despite the active support of senior pharmacists within the trusts, to fund what they may have considered was an expensive service targeted at a group of patients that were not a priority. There is also an unwillingness to see the service as replicable, partly because of the geography of Northumberland. None of the other community hospitals is as far as Berwick Infirmary is from the DGH. However the issues discussed here are common to all community hospitals. What of the future? One way to develop this service further is to incorporate the work into an LPS scheme to ensure recurrent funding. However, current guidelines require that these schemes include all associated dispensing within the LPS contract. Potential problems surrounding differential pricing between drugs used in primary and secondary care need to be overcome to make this a real possibility. In April of this year Northumberland Health became a Care Trust which incorporates social services within the organisation. Community hospitals are likely to eventually become managed within the care trust which may give us the opportunity to develop the scheme further. The service model described here can be developed further to include patients within nursing and residential homes and the vulnerable elderly living at home. The information provided to patients in this scheme is equally useful to carers, whether employed by residential care providers, home help providers or simply looking after a relative. Automation of the information leaflet production using data held on medication records could significantly reduce the time taken in providing the service.
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