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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Thank you for Listening