1. A domiciliary medication review service – ‘MESH’ Su Wood – Prescribing Support Services

2. Aim to: Understand what the Bradford MESH service is
Know how the referral system was developed
Understand the service delivery
Know the impact the service has had and the economic benefit to the NHS
Look at a domiciliary medication review service in relation to the NHS England pilot scheme

3. Plan Overview of the current pharmacist led MESH service
Challenges in running the service
Opportunities for MESH service development
National context
MESH: supporting the CCG objectives/vision
Group discussion
Feedback and Q&A
Summary

4. What is the problem?
What happens to a prescription once it has been issued?
Who knows?
An unmet need

5. What is the problem? A typical case Excess medicines found in a home
Included
58 insulin pens,
15 boxes test strips & 17 boxes lancets
34 bottles of Sno tears (many half used or out of date),
9 Seretide 125 inhalers & 10 Ventolin inhalers

6. What is the problem?
50% of patients with chronic diseases in the developed world are non- adherent.
The magnitude and gravity of non-adherence is such that greater worldwide health benefit could be gained through improving adherence to current medicines than developing novel treatments.
The consequences are waste, morbidity and hospital admissions.
World Health Organisation. adherence to long term therapies. evidence for action. Geneva: WHO; 2003

7. What is the problem? So that could mean for 50% of prescriptions:
Likelihood of clinical benefit reduced
Risk of harm increased
High cost for the NHS

8. How can a pharmacist in primary care help?

9. Who are we?
Prescribing Support Services: a multidisciplinary team providing a range of medicines management and optimisation services in primary care
‘MESH’ – MEdicines Support at Home – care home and domiciliary medication review.

10. Domiciliary review service model
REFERRAL
Referral from GP, integrated care , Social service. BRI. Virtual ward or community service providers
10 or more meds,
high risk medicines or multi morbidity
Computer based level 3 medication review
Identification of key priorities
Arrange face to face review
Undertake domiciliary or care home review
Complete action plan including holistic interventions ..liaison with specialist nursing teams, social services, primary care, family & carers
Follow up key actions : engagement with service providers
Focus on patient safety /admissions avoidance
DISCHARGE

11. High quality medication review delivered by experienced clinical pharmacists
To comprehensively review complex polypharmacy patients
To support prescribers with deprescribing agenda
To review a patient’s medicines holistically addressing and discovering:
Why and when medicines were started
Clinical issues – interactions, doses, monitoring, approprtieness of tx, untreated indications
Adherence issues – unintentional/intentional? Understanding patients health beliefs/attitudes towards medicines
Ordering, supply and waste reduction of medicines
To ensure the medication reviews are informed by current policy and guidance on medicines – MHRA/NICE/Safety alerts
To enable clinical priorities to be addressed, such as antipsychotics in dementia, reducing anticholinergic burden, inhaler issues, “Dosette” box issues

12. Outcomes – dependent on resource put in
Bradford Districts CCG
Bradford City CCG
population
 330,115
 118,567
Pharmacist resource
1.6FTE
1.4FTE
Net annualised savings
£150,000
£140,000
Number of dom reviews
772
957
Adherence issues
36%
32%
Reducing risk of harm
544 tests ordered
30 antipsychotics in dementia stopped
58 sedatives stopped/ reduced
76 anticholinergic burden reduced
12 NSAIDs stopped/ reduced
550 tests ordered
16 antipsychotics in dementia stopped
42 sedatives stopped/ reduced
255 anticholinergic burden reduced
29 NSAIDs stopped/ reduced

13. Cost saving Dependent on the resource put in
Annualised drug cost saving reported
Not reported savings on
- Reduced hospital admissions
- GP time
- Nurse time
- Social care time
- Carer burden

14. Recurring themes - inhalers
Example – ‘Approx 5-6 inhalers in use including Flixotide 125mcg, Seretide 125/25, Clenil 200mcg, Salamol 100mcg & Ventolin 100mcg mdi using 1 puff, four times a day of each inhaler.’
Photo ‘excess’ inhalers – lost clinical benefit and waste value £1,400
140/191(70%) technique corrected, 37/191(20%) inhaler device changed
How the MESH pharmacists are tackling this
- Informing GPs or respiratory nurses of non-adherance
- Educating patients on inhaler technique
- Providing written instructions to aid memory
- Follow up visits to check corrections are being maintained
- Involving relatives and formal or/informal carers in supporting patients

15. Recurring themes – ‘Dosette Box’ issues
Photo: multiple boxes in the home with only the odd dose taken out of any of them
How MESH pharmacists are tackling this
- Ensuring that an ‘MDS’ is appropriate and the best way to help the patient manage their medicines
- Using the medication review as an opportunity to rationalise medications and
implementing deprescribing where appropriate
- Making links with community pharmacy, social care and GP surgeries to ensure good
communication around medication issues
- Practices now encouraged to ask the MESH pharmacist to review before starting a
Dosette box where capacity allows

16. Recurring themes – ‘Waste’ - Excess medications in patient’s own home
£58,000 of excess meds found last year
How MESH pharmacists are tackling this
- Patient/family/carer education when excess medicines removed.
- Working with patients to run down stocks and implementing a system
for evaluating if more medicines are needed.
- Removing items from or adding messages to repeat templates indicating excess stock and date item next needs to be ordered.
- PSS waste poster being developed to put up in GP surgeries/pharmacies.
- MESH pharmacists’ contact details supplied to community pharmacists and GP receptionists if they identify medication over-ordering or potential hoarding

17. Stakeholder feedback Patient:
“It’s much easier now only taking things once a day, I get them all out of the way in the morning and I haven’t forgotten once”
“The reminder chart really helps and it’s handy on the fireplace” GP
“Excellent job. Now why did we not acquire your services a long time ago. Carry on good work.”

18. Challenges in setting up this service: workforce
Experienced clinical pharmacists
Clinical training and experience essential
Communication with patients/ carers and other HCPs
Team work
Lone working
Adequate resource
Governance
Safeguarding

19. Challenges: how do we find patients?
GP practice – known patients, searches (e.g. ≥ 65yrs, 10 or more meds, inhalers, housebound)
Referrals (S1 task and to MESH pharmacist) are received from:
• GP
• Integrated care service
• Community pharmacists
• Social services – assessment team
• Social services – provider team
• Hospital – BRI
• Home for Hospital
• Virtual ward
• Pulmonary rehab
• Physio/ OT

20. Challenges: multi-disciplinary communication
In the review process, MESH pharmacists work with:
• Patients
• Relatives/carers
• Community pharmacists
• District nurses
• Heart failure nurses
• Social services – assessment team
• Social services – provider team
• Hospital ward staff
• Hospital consultants
• Hospital medical secretaries
• Respiratory
• Elderly care discharge
• Virtual ward
• Interface

21. Challenges: KPIs
Data collection: cost saving and clinical parameters, error reporting and patient ‘stories’
Reporting: quarterly
Clinical benefit outcomes: risk reduction markers, patient stories
Cost saving outcomes: annualised drug cost saving
Patient and NHS stakeholder feedback

22. Challenges going forward
‘Over 85 population in Bradford has grown by 17% and will grow by 44% in the next 5 years’ – inevitable increase in polypharmacy patients
Increased resource needed for equity to all practices, to manage increased referrals from primary care, to manage increased in-reach/ out-reach requirements from secondary care.
Integrated care groups – aiming to a greater presence
Polypharmacy and de-prescribing agenda

23. Fits with national context
Focus on integrated care
Admissions avoidance
Polypharmacy and de-prescribing agenda
NICE guidance on medicines optimisation

24. MESH supporting the CCG agenda
Frail elderly
Patient-centred care
Self-care
Integrated care
Admissions avoidance
Polypharmacy and de-prescribing

25. Discussion in groups
What experience is there is the group, if any, of this type of service?
How do you see a domiciliary medication review service in your area?
What are the challenges to setting up a domiciliary medication review service in your area?
How would a domiciliary medication review service be good for a General Practice Pilot Site?

26. Summary – domiciliary review for the pilot scheme
Improve medicines safety
Improve patient outcomes
Improve management of long term conditions
Reduce GP workload
Improve communication between pharmacists, GP practices, social care etc
Increase patient confidence in pharmacists
Increasing roles of practice pharmacists

27. Summary – why you need to have a domiciliary medication review service
There is an unmet need
There is no point in prescribing
and issuing medicines if they are not
taken, both clinically and financially