1. Betsi Cadwaladr University Health Board 1000 lives plus Medicine Management Conwy Collaborative Project Project Lead: Liz Bond, (interim) strategic lead pharmacist, Mental Health BCUHB

2. Project Team Core team: Dr Manoj Rajagopal, consultant psychogeriatrician, Bryn Hesketh Dr C Close, GP Rhoslan Dr G Murphy, GP, Rysseldene Kerry McDonald, Memory Nurse, Bryn Hesketh Elaine Coulton, Care home manager, Pembroke lodge Steve Ford, Care home manager /owner, Pembroke House Gill Boothman, Fiona Jones, practice pharmacists Trudy Anderton, Practice support technician & data analyst Others: Locality lead GP (Conwy) Social workers Acute MH Ward manager Service user ( carer) CPN OPMH Program Group Lead

3. Why we started? National Reports highlighted dementia patients being prescribed antipsychotics inappropriately (IAP) Increased mortality in this population An estimated two thirds of patients could have their treatment reduced or stopped (Bannerjee) Estimated savings on antipsychotics £400k for BCUHB!

4. Aim of Project Multidisciplinary team approach Process Mapping to identify main gaps Key improvements that will:  Reduce unnecessary drug treatment for behaviour problems  Train carers with skills to identify triggers and manage behaviour without drugs  Improve quality of life for patients

5. Baseline Antipsychotic Audit 2011

6. PDSA improvement cycles 1. Training for care home staff 2. Tool to help identify, document and resolve challenging behaviour 3. Communication from secondary care 4. GP guidelines to support medication review

7. 1.Training for carers Training package set up by memory clinic nurse Offered to EMI care homes in Conwy Started rolling program of 4 modules:  Introduction to dementia  Communication  Person centred care  Dignity and challenging behaviour

8. 2. ACHAMPIONS tool Aim Quick identifier staff to objectively:  identify challenging behaviour  Prompt trigger  Identify potential solutions  Measure change after medication review. Summary for HCP review Aimed for use by non-nursing staff after training carried out. www.careforumwales.nhs.uk

9. 3. Proforma for documenting new antipsychotic treatment Aim: Improve communication to GPs when starting antipsychotics and ensure follow up Documents capacity and risk assessment Clarifies who will undertake review

10. 4. GP Management Checklist Aim: Summary guideline produced for GPs Guidance for initiation & review Document scanned & READ coded as MH med review for audit

11. Review process Patients identified on AP for BPSD Consultant to review every 6 months Review and treatment plan GP to review 3 months after consultant Pharmacist to link with review where able

12. Measuring change and improvement Headache! 1000 lives xls used for baseline but too time consuming Adapted for key indicators: Flags up overdue review to GP Monitored by practice team Other indicators included on Checklist

13. Rhoslan (reviews Feb12 onwards)

14. Rysseldene (reviews March 2012 onwards)

15. Barriers Care home Training  Lack of staff / increasing workload  Increasing demand for training GP Review & feedback  GPs reluctant to do initial review  Limited time (CH LES)  Many not known to consultant Sustainability  Consultant working OOH to complete reviews  Recognise the value of involving pharmacists!

16. Modified Process Patients identified from GP practices. Reconcile to CMHTe. Those not known to CMHTe reviewed by GP. Practice pharmacist to undertake medication review /follow up. Refer to secondary care if problems. CMHTe to hold own database

17. Next Steps 1. Training to be extended to all care homes across BCUHB from end May  Seek accreditation for course  Information to care homes on training and project awareness 2. Training for GPs and practice pharmacists through practice learning/ locality based education

18. Next Steps (contd) 3. Present results to OPMH consultants and support spread of learning  ADAPT MODEL TO OTHER AREAS  Improve discharge information! 4. Share learning & results across BCUHB