1. Preventing admissions in the frail elderly
Cherise Howson,
Care Home Pharmacist,
Croydon CCG

2. Objectives for this session
Background
Key learnings
Challenges
Practical examples

3. Background
The Health Foundation January 2015 report, Focus on: Hospital admissions from care homes
Older people living in a care home postcode had % more emergency admissions and A&E attendances than the general population of the same age,
Certain conditions were over three times more common in areas that had more care home residents. These include:
pneumonia
pneumonitis
Alzheimer’s disease
dementia
epilepsy
Care home patients were also less likely to be admitted for heart disease and circulatory system problems
The Health Foundation Focus on: Hospital admissions from care homes
The research used de-identified person-level data to analyse hospital admission rates among people aged 75 and over, for small geographical areas, from April 2011 to March They found that:
Health Foundation May 2013 Patients with dementia in acute hospitals experience poorer outcomes for all types of admission, stay longer in hospital, and are more likely to be discharged to a care home rather than to their own home

4. Background
In a 2004 UK study, the most common drug groups associated with admission due to adverse drug reaction were:
NSAIDs (29.6%)
Diuretics (27.3%)
Warfarin (10.5%)
ACE (7.7%)
Antidepressants (7.1%)
Beta blockers (6.8%)
Opiates (6.0%)
Digoxin (2.9%)
Prednisolone (2.5%)
Clopidogrel (2.4%)
Pirmohamed M., James S., Meakin S., Green C., Scott A.K., Walley T.J., et al. (2004) Adverse drug reactions as cause of admission to hospital: prospective analysis of patients. BMJ 329: 15–19.
Depending on which study you read it is estimated that between 5 and 20 % of hospital admissions are medicine -related. Be it from side – effects or in –efficient use of medicines.
80% of these admissions are predictable and therefore preventable.
Compared to 20 even 10 years ago there are more complex medicines available which can be more effective if used properly. Which raises some important questions around
Where do care home staff get their information from, what training is on offer?

5. Reactive vs Proactive Reactive behaviour Proactive behaviour
No interventions until a problem occurs
Care protocols /pathways
Not routinely assessing high risk patients
Routine assessments /reviews
Proactive prevention once a change has been identified. Prevent conditions from becoming severe enough to require hospitalisation through early identification and evaluation of changes in resident condition
Identify conditions that can be managed outside the hospital when it is feasible and safe and consistent with the resident’s preferences. The second strategy is we know that conditions are going to occur in this population, but not all of them require transfer to the hospital
Improve advanced care planning , many people may prefer to stay at home.
The use of palliative care, or hospice, as an alternative hospitalisation for residents who are in the end stages of life where hospital care may be harmful
A&E attendance
Prolonged hospital stays
Increased morbidity/mortality
Increased healthcare costs
Reduced hospital admissions
Improved morbidity/mortality
Increased QoL
Healthcare savings

6. Croydon approach
Integrated into the GP enhanced LES as a MDT approach to medication reviews
Time efficient
Less paperwork
Decisions agreed on MDT basis
Rolled out from May 11

7. Key learnings
A multidisciplinary team approach with direct GP involvement in the reviews results in the greatest interventions and enhances the knowledge of all involved.
It requires a two – pronged approach, review of both processes and systems as well as a clinical review
Engagement - Positive working relationships are integral
Educational - shared learning, advisory, supportive and facilitative approach
Agreed advanced care plans
Agreed process when visiting residents including information required
Practice staff understanding of the needs and responsibilities of care home staff including differences between residential and nursing
Communication within the practice for any changes
Systems for dealing with repeat prescription requests
Systems for dealing with urgent prescription requests
Communication systems with the dispensing pharmacy
When we analysed the hospital admission information, we discovered that the top admission reasons were:
• Falls
• Urinary Tract Infections
• Chest Infections
• Cellulitis
Developing care pathways on UTI, cellulitis, pressure ulcers, delirium - a systematic approach to guide healthcare professionals in managing a specific clinical problem.
In addition, there is a further end of life care pathway as we also discovered a significant concern about identifying when residents were entering the last stages of their life and in taking a proactive approach towards an end of life care plan.

8. Challenges Relatives Lack of understanding
Hospital admissions
Patient and Relatives
Care Home Staff
Other services GP
Relatives
Lack of understanding
Often pressurised through feelings of guilt
Care Home Staff
Knowledge base
Are they supported to make the right decisions?
Worry about complaints/CQC
Information overload, a lot of people going in and telling them what to do. Can also cause then to sit back and become disengaged
GP risk acceptance /confidence levels
Other services e.g. rapid response , coordinate my care not fully implemented

9. Health intervention scoring
The Hospital Avoidance Scale within the RiO healthcare management system adapted.
Interventions are assigned by the Clinical Pharmacist.
The score is determined by the probability that an adverse event would have occurred in the absence of an intervention
Scores are then used to calculate cost avoidance.
Interventions are examined for reliability.
Interventions are assigned by the clinical pharmacist to the most appropriate category and a rating score.

10. Intervention categories were developed based on the work of a Pharmacist working with the Partnership for Older People’s (POP) Service, where its use was essential in ensuring that the pharmacy element of the service continued to be commissioned
The classification of interventions is subjective.

11. Examples of RIO interventions
Scoring
Level 1 = no likelihood
Level 2 = possible
Level 3 = likely
 Examples of RIO interventions
Level 1
Lifestyle advice
Unnecessary food supplement stopped
Level 2
Long – term steroids; bisphosphonate started
Spacer device added for patient with asthma with poor inhaler technique
Level 3
Insulin instructions changed; resident was being given novorapid despite low blood glucose levels
Diazepam rectal added for patient with poorly controlled epilepsy
Scoring depends on: type of intervention; type of drug; and individual’s co-morbidities.
Medium and low scores are the most frequent probabilities assigned to the interventions. This reflects findings obtained in the majority of other work streams which have implemented the same method of calculating cost avoidance .
indicated that the primary scorer was assigning probability scores in a manner consistent with other pharmacists.
The intervention not the problem is scored

12. Economic evaluation
A cost avoidance figure of £2,800 is attributed to each potentially saved hospital admission.
Assigned to each level 3 intervention.
Estimated that 10% of those receiving level 2 interventions would be considered likely to avoid a hospital admission.
(based on the average length of stay for an older person presenting at A&E.)
Demonstrate cost savings which show it pays for the time of a FTE Pharmacist
Need to be careful in that with a lot of groups going into the care homes can lead to double counting and also whether your intervention alone counted towards reducing hospital admissions.

13. Drug cost savings Based on DT tariff costs for that month Annualised
The number of dispensing fees are also calculated, remember ONS can attract multiple fees
At the end of the day fewer medicines lead to reduced risk of medication error (CHUMS study indicated that on any given day 7 out of 10 resident's can be subject to at least one medication error.
Fewer medicines can free up Nurses and Senior Carers to provide more patient centred care.
One of the other things we have been doing is tracking NHS numbers for 6 months before an d6 months after intervention. Whilst we overestimated on the number of hospital admissions , it was found that there was a reduction in bed days. Also this doesn’t pick up people who did not go into hospital because of intervention but would have gone in it they hadn’t had an intervention.

14. Medication reviews with one GP practice
89 residents reviewed
168 interventions made
level 1 – 156
level 2 – 9
level
Top 5 types of interventions
Unnecessary medicines (32%)
Optimising current therapy (17%)
Side effects advice (15%)
Incorrect/ inadequate directions(11%)
Synchronisation of medicines to reduce waste(5%)
Annualised drug cost savings of £8K
Across 4 care homes
Top 5 (80%) of interventions
What we commonly find
Rarely re-start medication

15. OVER TO YOU…….

16. Example of RIO scoring Medication Seretide 250 inhaler 2p bd
Salbutamol inhaler 2 p prn
Ipratropium 2p qds
Senna 2 nocte
Citalopram 20mg od
Clopidogrel 75mg od
Amlodpine 5mg od
Simvastatin 20mg nocte
OTC - ibuprofen
Metformin 500mg 2 bd
Glicazide 80mg od
Interventions
RIO score ?
Inhaler technique checked. Correct
technique demonstrated.
Spacer device added
Advice on re-ordering and cleaning
Advised MAR to include salbutamol
Senna changed 1 or 2 at night prn
Senna original pack as now prn dose
Ibuprofen changed to prn paracetamol
Alcohol use – advice given as open door
policy, monitor lager in room
Lansoprazole 15mg started
Advised on benefits of flu vaccine – at
risk group
Advice given to carers on using diabetic
diagnostic device
Patient JM 70 year old male COPD , essential hypertension, type 2 diabetes , stroke 2013, gastritis unidentified , h/o depression, non smoker
Infected exacerbation of COPD 1 month ago - hospitalised
Access - none identified
Cognitive – none identified
Physical /administration
Self administration of salbutamol, not, included on the MAR chart inhaler technique found to be poor, would take 2 quick puffs, breathing not coordinated properly
Senna was taken occasionally, ‘don’t get constipated’ , but wanted to have something just in case
Side effects / clinical / other
Citalopram started 3 months ago, was down when sister who was in the same care home passed away.
Keeps lager in his room and reports has 2 pints once a week when goes to social club with friends
BMs monitored daily, results range 7 – 10 before breakfast. No hypos
Beliefs about medicine or condition
ibuprofen increase risk of bleeding with clopidogrel – discussed with resident, taken when knees get painful, stopped also on citalopram

17. Example of RIO scoring Medication Seretide 250 inhaler 2p bd
Salbutamol inhaler 2 p prn
Ipratropium 2p qds
Senna 2 nocte
Citalopram 20mg od
Clopidogrel 75mg od
Amlodpine 5mg od
Simvastatin 20mg nocte
OTC - ibuprofen
Metformin 500mg 2 bd
Glicazide 80mg od
Interventions
RIO score ?
Inhaler technique checked. Correct
technique demonstrated.
Spacer device added
Advice on re-ordering and cleaning
Advised MAR to include salbutamol
Senna changed 1 or 2 at night prn
Senna original pack as now prn dose 1 2
Ibuprofen changed to prn paracetamol
Alcohol use – advice given as open door
policy, and lager in room
Lansoprazole 15mg started
Advised on benefits of flu vaccine – at
risk group
Advice given to carers on using diabetic
diagnostic device 3
Patient JM 70 year old male COPD , essential hypertension, type 2 diabetes , stroke 2013, gastritis unidentified , h/o depression, non smoker
Infected exacerbation of COPD 1 month ago - hospitalised
Access - none identified
Cognitive – none identified
Physical /administration
Self administration of salbutamol, not, included on the MAR chart inhaler technique found to be poor, would take 2 quick puffs, breathing not coordinated properly
Senna was taken occasionally, ‘don’t get constipated’ , but wanted to have something just in case
Side effects / clinical / other
Citalopram started 3 months ago, was down when sister who was in the same care home passed away.
Keeps lager in his room and reports has 2 pints once a week when goes to social club with friends
BMs monitored daily, results range 7 – 10 before breakfast. No hypos
Beliefs about medicine or condition
ibuprofen increase risk of bleeding with clopidogrel – discussed with resident, taken when knees get painful, stopped also on citalopram also has hypertension
One of the things need to consider is the timescale in terms of exposure to the intervention e.g. cleaning of the spacer device and reducing exacerbation

18. List the interventions you would make and assign a RIO score.
Case Study
EC is a 89 year old female who has been at the care home for 3 years.
Metformin 500mg 2 bd
Gliclazide 80mg 1 bd
Hydroxine 25mg nocte
Omeprazole 20mg
Ramipril 5mg 1 od
Amlodpine 10mg 1od
Atorvastatin 40mg
Cavilon durable barrier cream to be applied to sacral area
Aquacel dressing 10cm sq
Cetraben emollient apply daily
Citalopram 10mg mane
Citalopram 20mg mane
Oxybutynin 5mg bd
Warfarin 1mg, 3mg and 5mg asd
Latanoprost eye drops 1 drop affected eye(s) at night
Docusate 100mg 2 nocte
Loperamide 2 initially then one after each loose
Digoxin 125mcg daily
Adcal D3 1 bd
List the interventions you would make and assign a RIO score.
Identify what are the
desired outcomes, patient perspectives and HCP perspective
therapeutic goals
medication related problems
Prioritise interventions
Plan patient with diabetes and AF what would you check are in place?
Assign RIO scores