Preventing admissions in the frail elderly Cherise Howson, Care Home Pharmacist, Croydon CCG cherise.howson@croydonccg.nhs.uk

Objectives for this session Background Key learnings Challenges Practical examples

Background The Health Foundation January 2015 report, Focus on: Hospital admissions from care homes Older people living in a care home postcode had 40 - 50% 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 2012. 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

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 18 820 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?

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

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

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.

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

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.

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.

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

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.

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.

Medication reviews with one GP practice 89 residents reviewed 168 interventions made level 1 – 156 level 2 – 9 level 3 - 3 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

OVER TO YOU…….

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

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

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