Patient ownership

Lewisham delivered an integrated interface care model to support patients with long-term conditions to manage their own medicines

The management of almost all long-term conditions involves the use of medicines and yet there is growing evidence that indicates between 30-50% of patients world-wide do not take their medicines as recommended.^1,2,3 There is also a significant risk that patients’ medicines will be unintentionally altered when they move between care settings as information is not always effectively transferred or understood.
Indeed, only 16% of patients world wide who are prescribed a new medicine take it as they are supposed to, experience no problems and receive as much information as they need.⁴ With the NHS drug spend in 2012/13 at £13.8 billion, suboptimal medicines use leads to poor patient outcomes and also represents an unprecedented economic challenge.

The challenge
In Lewisham, we, NHS Lewisham Clinical Commissioning Group (CCG), Lewisham and Greenwich NHS Trust and London Borough of Lewisham, began our journey to improve patient care in April 2013. We set out to improve both patient experience and patient outcomes from prescribed treatment. To achieve this, co-ordinated services were key, particularly with regards to the interface between health and social care.
By involving key stakeholders, including patients, carers and social care providers, during the planning/development stage of this project, key issues emerged:

There was no defined care pathway.
Decisions about how to support patients involved multiple teams across several organisations, making many (and often conflicting) decisions.
Almost all assessments lead to a monitored dosage system blister pack (where pharmacists re-package tablets into packs with the days of the week and times of the day printed on them). There were few individually targeted solutions and little follow-up of patients.
There was no standardised referral process for social care support, and little joint working between health and social care.

All involved thought that they were doing the best for patients. However, they were responding with ‘one size fits all’ solutions.
Patient engagement informed us of a lack of shared decision making. Firstly, patients wanted a safe system that allowed them to maintain independence and remain in control. Secondly, many patients that were receiving their medicines from local pharmacies in multi-compartment compliance aids felt the appropriateness of the system did not meet their individual needs. Thirdly, it was the housebound and recently discharged patients from hospital who were transferring to a care home, or with a social care package that involved medication support, appeared to be most at risk and yet had the least access to services.

The model
Targeting resources to deliver patient-centred care, in January 2014, Lewisham CCG, commissioned the Lewisham Integrated Medicines Optimisation Service (LIMOS) to support patients that have or are at high risk of medicine related problems to enable them to remain independent, and at home, for as long as possible.
The model (Figure 1) involved partnership working with professionals across both health and social care and follows the patient across the secondary/primary care interface. It represents a new role for the specialist LIMOS pharmacist and pharmacy technician – one that not only facilitates seamless communication with the patient, but ensures patients with long-term conditions remain involved and are central planning their own care.
Key stakeholders included leads from adult social care, domiciliary care providers, the CCG, the local pharmaceutical committee and community pharmacists, local GPs, community service providers and the local secondary care trust. Gaining agreement and establishing a shared vision and strategy towards achieving medicines optimisation with key stakeholders across health and social care not only promoted partnerships working across care boundaries, but also supported the coordination of services to enable transformational and sustainable change. Such partnership working, across a coordinated care pathway, ensures that a patient-centred pharmaceutical care plan is not only developed, but also implemented across care settings.

Patient-centred care
LIMOS directly assesses and reviews all medicine issues for referred individuals. This is facilitated by access to full medical records, either in hospital or via GP surgeries, with patient consent. Assessments can be undertaken in the hospital setting or as part of a home visit.
Direct discussion with the patient and/or carer/relative not only provides an insight into the way in which an individual uses their medicines but there is also an understanding of their experience, physical and mental state.
Following liaison with the GP, community pharmacist and the social service team, an integrated and deliverable pharmaceutical care plan is developed and agreed with the patient and all those involved in their care.
LIMOS provides regular follow up to patients, communicating with the carer or relative for about one month after the initial review. This may include a revisit to the patient’s home to ensure the package of care has met the individual’s needs.

System-wide coordinated care
The service and its associated pathway has improved safety for patients by developing a whole system approach to care. Prior to this initiative, we were reliant on social care staff who, without any clinical knowledge, were responsible for assessing patients.
Secondly, care workers without appropriate medicines administration training were responsible for administering medicines from blister packs (which meant that they couldn’t identify what they were giving), against hand-written medication charts that were often not fit for purpose.
To tackle these issues we agreed a joint pathway across health and social care, as well as primary and secondary care, to ensure that we have a consistent approach, and that patients now have specialist assessment provided by the LIMOS team.
Care workers no longer administer from blister packs, which means they can now identify the medicines they are giving, and help with any medicine outside of the blister pack such as liquids and inhalers, which they previously refused to do.
We had to address concerns regarding the ability of care workers to do this, so we have developed and commissioned specialist training that has been delivered to 1,400 care workers to date. We have also commissioned community pharmacists to produce the medication charts for care workers to complete at the point of dispensing – to ensure accuracy, and prevent transcription errors.
Given it is reported world wide that 60% of medication errors happen during transfer of care,^5,6,7 this model enables LIMOS to work across traditional care boundaries to proactively identify and resolve any errors which could result in harm. Both qualitative and quantitative data demonstrate outcomes delivered to date. Patient and referrer feedback has been formally collated and evaluated. Comments are positive from both users and those referring to the service suggesting improved patient understanding and taking of medicine by this group of high risk patients.

Outcomes and long-term impact

In total 469 patients have been seen by the service, 947 interventions in their care were made by the LIMOS team.
150 A&E attendances were avoided.
30 hospital admissions were avoided.
Reducing the number of medications and frequency of medication doses that patients had to take over the course of a day resulted in a reduction of 139 daily visits required to support medication administration.
Direct/indirect savings of £600,000 per annum.

Reviews of service interventions (which have been externally validated) demonstrate that for the 469 patients seen during the first year of the service, 150 potential A&E attendances have been prevented, 250 unnecessary medicines have been stopped and there has been a significant reduction in the need for social services support for medicines administration. What the outcomes show in their totality is that for every £1 spent on delivering the service, £2 is saved across the health and social care environment. These savings are additional to the improved quality in care and expected improvement in health outcomes through all those involved in the prescribing, dispensing and administration of medicines working to support patients remain independent within the community.

Cleo Butterworth, medicines optimisation lead, Lewisham CCG.

References
1 Sabaté E, editor Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization. 2003.
2 DiMatteo MR. Variations in patients’ adherence to medical recommendations a quantitative review of 50 years of research. Med Care 2004; 42:200-9.
3 Pirmohamed M, James S, Meakin S, Green C, Scott A K, Walley TJ, Farrar K, Park BK, Breckenridge AM. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ 2004; 329: 15–19.
4 N Barber, J Parsons, S Clifford, R Darracott, R Horne. Patients’ problems with new medication for chronic conditions. Qual Saf Health Care 2004; 13: 172-175.
5 National Patient Safety Agency and National Institute for Health and Clinical Excellence. Technical safety solutions, medicines reconciliation. 2007 nice.org.uk/guidance/psg1(accessed 2 February 2016)
6 Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Archives of Internal Medicine 2005;165:424–9.
7 Rozich JD, Resar RK. Medication safety: one organization’s approach to the challenge. Journal of Clinical Outcomes Management 2001;8:27–34.