Delivering a medicines optimisation in care homes service for South Warwickshire

Medicines optimisation in care home (MOCH) services integrate pharmacy support into existing teams to improve the quality of patient centred care and reduce the risk of harm from medicines to residents.

Arden & GEM’s MOCH team supported one South Warwickshire care home by conducting medication reviews, reviewing care home systems and advanced care planning processes, providing training for staff and increasing multidisciplinary working.

Over a six-month period, this support led to over 100 medication interventions which have improved patient care and safety while achieving savings.

The challenge

One in seven people aged 85 or over permanently live in a care home. Residents in care homes account for 185,000 emergency admissions to hospital each year, with more than 40% of these admissions potentially avoidable. Evidence suggests that many people living in care homes are not having their needs assessed and addressed as well as they could be, often resulting in unnecessary, unplanned admissions to hospital and sub-optimal medication regimes.

The NHS England medicines optimisation in care homes (MOCH) programme was designed to encourage the integration of pharmacists and pharmacy technicians into existing multidisciplinary teams to improve the quality of patient centred care and reduce the risk of harm from medicines.

The programme is supported by the Pharmacy Integration Fund, meets the objectives of the NHS Long Term Plan and can support Primary Care Networks to implement the Care Homes Direct Enhanced Service.

Within South Warwickshire, Arden & GEM has a specific MOCH team – known as the Medicines Optimisation Plus Team – comprising three pharmacists, supported by a CCG clinical GP lead, to focus on improving the health and wellbeing of complex and frail patients.

Our approach

In March 2019, the Arden & GEM MOCH team began providing support to a Warwickshire care home, with 44 residents, as part of a CCG commissioned pilot.

The key aims of the MOCH service include:

• Delivering a high-quality medicines optimisation service to residents with complex needs, ensuring medicines are used safely and appropriately to achieve healthcare needs
• Supporting better medicines systems and processes in the care home e.g. reducing waste, improve adherence to national guidance
• Developing bespoke training to support care home staff to meet their learning needs
• Evaluating advanced care planning processes
• Integrating with existing services accessed by residents including secondary care, allied healthcare professional teams and specialist nursing teams.

Building relationships
Service development began by forging strong relationships with the care home and local GP practices. The home was assigned a ‘link pharmacist’, as their main point of contact, and this arrangement remains in place for the review of new residents, post-hospital admissions and support with queries or further educational needs.

The MOCH team also worked closely with the IT team to design and develop a template to be embedded within the GP system to aid with recording and extracting data from the medication reviews.

Conducting medication reviews
Our MOCH service conducted level 3 medication reviews for 41 of the 44 residents, with data and changes recorded on the new GP system template. The reviewed residents had an average age of over 85 years, an average Rockwood clinical frailty score of 6.9 (9 being the highest possible) and approximately 80% were deemed to be at a very high risk of falls.

Of the residents reviewed, over 70% had changes made to their medication, demonstrating the opportunity for medicines optimisation in this cohort of patients:

• 11% of changes were reductions to, or the stopping of, sedating medicines
• 9% of changes were reductions to or the stopping of proton pump inhibitors
• Nearly a quarter of interventions were to simplify and avoid duplication, waste and confusion in emollient use.

Reviews also included an assessment of falls risk and clinical frailty, with Rockwood scores completed and assessed as needed.

Advanced care planning
An audit of anticipatory care planning at the care home found that while 89% of residents had a plan in place, all ReSPECT forms were incomplete with missing or partial details. This meant the ability to use them to improve quality of life and prevent admissions was potentially hampered by inaccurate or incomplete assessments and documentation.

This initial data gathering has fed into system-wide discussions regarding Advanced Care Planning.

Staff learning and development
Pre-intervention questionnaires carried out with home staff identified areas for learning and development. The MOCH team worked with the home to deliver sessions on ‘Infections’ and ‘Nutritional Support’ aligned to their education time. These sessions were well attended by a variety of staff members who provided positive feedback.

The outcomes

A South Warwickshire care home was supported by the CSU’s MOCH team from March to October 2019. This has led to a number of benefits for the care and safety of patients:

• Over 100 medication interventions have been made as a result of reviews
• Medications have been rationalised using nationally recognised toolkits aimed at reducing morbidity and mortality
• Medications policies (e.g. covert administration) and processes have been improved
• Multidisciplinary working has increased. For example, one diabetic resident was struggling to take glucose readings. Through liaison with a nurse specialist, a new continuous blood glucose monitoring system was implemented and care home staff were trained in its use
• Medication interventions have led to annualised savings of over £5k.

The successful implementation of the service has led to the team identifying further homes to support across South Warwickshire, in line with the interim service models introduced following the COVID-19 pandemic.