Medway Care Home Team Dr Sanjay Suman – Consultant Geriatrician - Medway Foundation Trust Prina Sahdev – Care Homes Pharmacist - Medway CCG

Visiting Medical Officer role replaced by Care Home Team Background Visiting Medical Officer role replaced by Care Home Team 12 month Pilot 12 nursing homes covered Approx 470 beds Dr suman

Integrated Team Pharmacist Advanced Nurse Practitioners x 2 Medway CCG Medication Reviews, Medication Reconciliation, Reduce Wastage, Support with CQC visits, Training Advanced Nurse Practitioners x 2 Medway Community Healthcare Reduce GP workload, Support Nursing Homes, reduce Hospital admissions, training End Of Life Facilitators Advance Care Plan, Training, Support with Syringe Drivers, Support residents and their families, supplementary prescribers Consultant Geriatrician Medway Foundation Trust Support with virtual ward rounds, Medication reviews, Education, support Prina and DR Suman

Nursing Home Pathway Nurse Community teams (Diabetes, Respiratory etc) Care Home team Admin (Triage) Nurse Consultant Geriatrician (Weekly Virtual Ward Round) Community teams (Diabetes, Respiratory etc) Pharmacist GP End of Life Facilitators prina

Key Performance Indicators 15% reduction in ED attendances (40 attendances) 15% reduction in ambulance conveyance (40 conveyances) Reduction in non-elective admissions by 0.85 ratio to ED attendances (34 admissions) Achieve £100,000 prescribing savings in nursing homes 100% of residents identified as end of life and that have an advanced care plan in place Residents supported to achieve their preferred place of death Increase nursing home satisfaction Dr Suman

12 Month Review KPI including pilot target Target at 12 months Achieved at 12 months 15% Reduction in ED attendances (40) 40 158 Achieve £100,000 Prescribing Savings £100,000 £142,386* 100% Residents identified as end of life with and advanced care plan in place 100% 15% Reduction in ambulance conveyances (40) Reduction in NEL admissions (34) 34 24 dr Suman talks about NEL admissions

Pharmacy Savings Patients reviewed Average age of patient 356 Patients reviewed 84 Average age of patient 6 Average number of medications 4 Average number of recommendations made / review £432 Average saving per review ** Central Nervous System, Nutrition, Cardiovascular £££ Nutrition and Woundcare Prina

Nurse Perspective Resistance to input from NHs Resistance to end of VMO scheme Data collection – patchy, time constraints Getting information from Nurses in homes Hosted independent Forums - includes training Relationships built successfully Close working with GPs prina

Pharmacist Perspective No resistance to input Willingly accept advice and feedback Audit visits to prepare for CQC audits and to support good practice Close relationship with GP practices – rapid access to information and advice Difficulties with procedures – each home is individual Medication reviews in line with Local Formulary and initiatives Prina

Lessons Learnt Pilot extended for further 6 months Benefits from proactive work not evident Internal Referral sheet set up Communication within integrated team not recorded by nurses Residential Beds to be covered by CHT Residential units in care homes skewed figures Workshop organised Pathways drafted Lack of clinical pathways Dr Suman

Future Hopes Better links with acute frailty pathway – From front end of hospital Early facilitated discharge – from wards Better links with Out of hours teams – follow up with end of life patients Prina

Thank you for Listening