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Abstract
Background and objective There is limited published data on coordinated care models focusing on addressing suboptimal medicines use, which not only leads to poor patient outcomes but also represents an unprecedented economic challenge. This paper describes the key components of a system-wide coordinated care model adopted by, and integral to, the Lewisham Integrated Medicines Optimisation Service (LIMOS).
Methods and results LIMOS consists of specialist pharmacy team members who rotate geographically between primary and secondary care organisations, accepting referrals from health and social care professionals within both settings. LIMOS provide a formal pathway for the referral of patients with medicines-related problems for assessment, support and follow-up to review access, adherence and clinical issues. An integrated and deliverable pharmaceutical care plan is developed and agreed with the patient and all involved in their care. Regular follow-up, by either phone or further visits to the patient's home, is provided after initial review to ensure interventions continue to meet individual needs. Outcome measures are being collated for service evaluation. Enablers underpinning successful service delivery include the ability to share information and refer across traditional boundaries to ensure that patient-centred care is delivered together with the implementation of a joint health and social care medicines policy.
Conclusions An approach addressing an identified gap in meeting the medicine support needs of the local population has been described. The essential components underpinning LIMOS should be explored by other health and social care organisations considering the establishment of a new, or development of an existing, medicines optimisation model.
- CLINICAL PHARMACY
- PHARMACY MANAGEMENT (ORGANISATION, FINANCIAL)
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Introduction
The management of almost all long term conditions involves the use of medicines and yet there is a growing body of evidence that indicates between 30% and 50% of patients do not take their medicines as recommended.1 There is also a significant risk that patients’ medicines will be unintentionally altered when they move between care settings as information on changes to medicines is not always effectively transferred or understood.2 Only 16% of patients who are prescribed a new medicine take it as prescribed, experience no problems and receive as much information as they need.3 Medicines optimisation is not only about ensuring that the right patients get the right choice of medicine, at the right time, but is a more a patient-focused approach which places the individual at the centre of the decision making process to maximise outcomes through the delivery of high quality care. With the National Health Service (NHS) drug spend in 2012/2013 equating to £13.8 billion, suboptimal medicines use not only leads to poor patient outcomes but also represents an unprecedented economic challenge.
There is limited published data relating to the establishment, structure and operation of system-wide coordinated care models across the interface focusing on medicines optimisation. Despite this, where models exist there is known variation in how these services are commissioned and provided. Recognising the need to build on existing systems but also appreciating that no single sector or profession will be able to deliver medicines optimisation in isolation, an integrated model of care to support patients to manage medicines and retain independence was developed. This model operates not only across the traditional primary and secondary care interface but also across professional, health and social care boundaries.
Objective
In this paper we aim to describe the key components of a system-wide coordinated care model adopted by, and integral to, the Lewisham Integrated Medicines Optimisation Service (LIMOS).
Overview of model
LIMOS consists of a team of four specialist pharmacists (band 8a) and two pharmacy technicians (band 5). As a unique collaborative model shared between the clinical commissioning group (CCG) and hospital, staff rotate to work geographically in both the primary and secondary care settings. This is a key enabler for service delivery as it permits effective working relationships to be formed with the wide range of individuals with whom communication is essential to coordinate the integrated package of care around medicines use. LIMOS also brings together two arms of a common team that works across various interfaces aiming to reduce medication errors at a part of the pathway identified with highest risk. An overview of the LIMOS model is shown in figure 1.
Overview of the Lewisham Integrated Medicines Optimisation Service (LIMOS).
LIMOS aims to support patients identified as having or being at high risk of medicine related problems to enable them to remain independent, and at home, for as long as possible. Such groups include those with potential medicine-related hospital admissions, those who have or require a care package for medicines support, those with new requests for multi-compartment compliance aids (MCAs), or those less likely to access community pharmacy support through Medicines Use Reviews (MUR) or New Medicines Services (NMS), including the house-bound and those with mental health issues.
LIMOS receives referrals from health and social care colleagues in both the primary and secondary care setting. Although not exhaustive, this includes general practitioners (GPs) and hospital medics, district nurses and ward staff, community matrons and specialist nurses, and community pharmacies, as well as Hospital Admission Avoidance Teams (HAST), domiciliary care workers, social care teams and voluntary care organisations. Irrespective of where the referral is received, the service model remains unchanged. LIMOS directly assesses and reviews all medicine issues for referred individuals taking into consideration access (obtaining a safe and regular supply of medicines), adherence (intentional and non-intentional), day-to-day management and clinical aspects. A robust review is further supported by access to full medical records with patient consent. Direct discussion with the patient and/or carer provides not only an insight into the way in which an individual uses their medicines but also an understanding of their need, experience, and physical and mental state. An integrated and deliverable pharmaceutical care plan is developed and agreed with the patient and all those involved in their care. A range of interventions can be introduced by LIMOS as part of the medicines optimisation process, including:
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Rationalisation of medication regimens to facilitate adherence, for example reduction in the frequency of dosing from three times daily to once daily and/or reviewing medications no longer required in collaboration with the patient's doctor.
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Provision of information to patients to increase understanding of the importance of taking their medicines and facilitate self-management.
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Liaison with community pharmacy to implement adjustments to support self-care, for example large print labels, medication reminder charts or monitored dosage systems.
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Use of technology to prompt administration, for example alarmed systems or automated telephone calls.
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Setting up formal or informal carer administration, supported by a community pharmacy supplied medicine administration record chart.
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Signposting to other national support services, for example MUR or NMS.
With the constraints of time it is not always possible to review, implement and assess the impact of interventions employed to resolve medicines-related problems identified during the hospital stay. This unique model allows members of the hospital-facing LIMOS team to refer a patient for follow-up by the community-facing arm of the service to establish the outcome of any interventions made. A visit to the patient's home may also highlight further unidentified medicines-related problems that are only apparent in the home setting. The service prioritises cases according to individual need; most patients will receive an initial assessment within 3 days but not longer than a week from referral.
Regular structured follow-up is provided by the LIMOS team for about 1 month after initial review. This may involve either a phone call, or further visits to the patient's home to ensure the interventions introduced continue to meet individual needs. Communication is vital, throughout the episode of care and at the point of discharge, with the patient and all relevant professionals across both health and social care, to enable the coordination of interventions and review of patient outcomes.
Local infrastructure that supports service delivery
Having described the model in detail, it is essential to understand the infrastructure that exists locally that underpins the successful delivery of LIMOS. The key elements of an integrated interface care model focusing on medicines support and optimisation are further explored below.
Patient centred care
Scoping work, including forums with a number of patient/carer groups, identified a key message that needed to be incorporated into service developments around medicines optimisation. Patients and carers wanted to retain responsibility and independence around medicine use where possible, with more input into decisions made.
Interlinked with this was the issue that throughout health and social care services, the solution to almost all medicines-related problems was invariably the use of an MCA, often without proper assessment to understand the underlying problem, which can be multifactorial. In addition, without a pathway to enable assessments to be undertaken, requests for MCAs were being made from a plethora of professionals within both health and social care (as well as from relatives and informal carers) with no clear rationale or ownership for ensuring that the MCA met an individual's need. The problem was further exacerbated by the fact that policies for most local care provider organisations insisted that medicines should be dispensed in MCAs for staff to be able to support medicines administration. As such, often the decision to supply an MCA was meeting the needs of a system, rather than the individual, whose problems with medicines could be as simple as accessing medicines or understanding their need. As part of the system-wide approach, requests for the initiation of an MCA must now be either discussed with or managed through LIMOS using the standardised assessment tool. LIMOS addresses an identified gap in service provision whereby there is now a formal pathway for the referral of patients with medicines-related problems for assessment, support and follow-up. In practice this means not only stopping MCAs where patients’ needs are not met but also initiating them where appropriate to maintain independence as a key aim.
Perhaps one of the greatest challenges posed in developing the service related to the need to convince care providers that it was possible to safely administer medication to people without the need for an MCA. A significant concern from social care services has been that changing such practices would require increased resources at a time when funding available for services is decreasing. Local leadership and the establishment of a shared vision in the borough on how best to support patients with medicines, together with the willingness, across all organisations, to challenge the status quo, has been fundamental in overcoming this.
Collaborative and partnership working
Gaining agreement and establishing a shared vision and strategy towards achieving medicines optimisation with all stakeholders across the borough not only promoted collaborative and partnership working across care boundaries, but also supported the coordination of services to enable transformational and sustainable change. Key stakeholders included leads from adult social care, domiciliary care provider organisations, CCG board members, the Local Pharmaceutical Committee and community pharmacists, local GPs, community services providers and the local secondary care Trust. In practice, for LIMOS this means that all parties agree to the sharing of information, with patient consent, across a coordinated care pathway. Such partnership working allows an individual's needs for support around medication to be considered within the wider context of their often complex care. This ensures that a patient centred pharmaceutical care plan is not only developed, but also implemented across care settings. Although there was early engagement from key stakeholders, it is important not to underestimate the efforts and time required to ensure that potential referrers to the service understand both the types of patients who can be supported by the service and how referrals can be made. A service user leaflet was developed and widely disseminated. Ahead of the service launch, forums within both health and social care settings were targeted to promote the service. These included GP locality and neighbourhood network meetings, admission avoidance and supported discharge teams, community pharmacy forums as well as social care team meetings in both hospital and primary care. While attending small group meetings was time-consuming, it gave stakeholders the opportunity to ask questions and has ensured that referrals made have been appropriate from the outset. Successful roll-out also involves face-to-face interactions with various colleagues through individual patient case management and the sharing of care plans with all parties involved.
Information flow across organisational and professional boundaries with differing information technology (IT) systems and records presents a challenge in terms of the time associated with both written and verbal communication necessary to ensure actions and plans are appropriately formed and effectively communicated. A consultation platform which integrates with the main GP system used locally, access to the new locally developed virtual patient record, and extension of the use of NHS net by community pharmacy providers are solutions currently being developed to overcome IT challenges faced to date.
Joint medicines policy
Facilitated by the partnerships outlined above and led by medicines management teams across the interface, an overarching joint medicines policy was developed to set out, for both NHS and social care teams, how patients should be supported in managing their medicines. The policy defines a service that promotes independence and facilitates the care of people in their own homes. It also provides a standardised assessment tool that can be used by all multidisciplinary team members to assess the medicines support needs of an individual. The vision to commission an extensive programme of training for over 1000 care workers from 22 domiciliary care agencies was not only integral in enabling the delivery of social care services in which staff are competent to support patients with the administration of their medicines in their own homes without the need for an MCA, but has also equipped staff within the social care environment with the skills and knowledge to recognise medicine-related problems that may arise with the changing needs of the patents they support. The policy defines patients’ needs around medicines into three levels of care:
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Level 1: requires help ordering and collecting prescriptions and advice on safe storage.
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Level 2: level 1, with the patient retaining responsibility for their medicines, but the patient requires supervision with self-administration or requires help to open containers and/or a reminder to take medicines.
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Level 3: requires total medicines management, which includes direct administration from original packs against a community pharmacy produced medicines administration record chart.
LIMOS provide a specialist service to which these teams refer to ensure patients’ needs around medicines are fully assessed. This pathway provides a structured and coordinated approach to ensure that any necessary changes can be agreed and shared with all those involved in the care of an individual.
Workforce: the LIMOS team
In developing the LIMOS model consideration was not only given to the number of staff required but also to the skill set and mix necessary for staff to ensure effective service delivery. Mindful that the service model required two arms of an integrated team, the objective was to create a team to enable half the team to work within the hospital and half the team to work in the community. The staff rotate between hospital and community base on a 3-monthly cycle. Clearly with any new service estimating demand and appropriate resources is always difficult, but it was believed that the ‘four pharmacists and two technicians’ model offered the best starting position, enabling staff to be absent without the need to ‘pull’ staff from one area to the other, safeguarding service provision across the whole pathway.
Core characteristics identified as essential in the recruitment and selection of staff to the team included the demonstration of excellent interpersonal skills, effective clinical skills and knowledge, as well as a pragmatic approach to problem-solving. Experience of working in, together with an understanding of, both primary care and hospital pharmacy has also proved to be beneficial for the posts. As a new role for pharmacists, engaging other colleagues within health and social care teams to undertake actions outside of the direct remit of the team, for example onward referrals, has required not only the development of clear pathways that ensure the clarity of roles but also strong negotiation skills from team members in some cases to follow through recommendations made. However, the adoption of a team approach, in addition to better outcomes for patients and good feedback from service users, has led to the team being welcomed and viewed positively.
Outcome measures
At the time of writing, outcome measures are being collated for full service evaluation. Initial service statistics indicate that 172 patients have been referred and managed by LIMOS since service establishment in February 2014. The mean age of patients referred is 77 years (range 30–97 years). Of interest, 69% lived alone. A similar number of referrals have been received and managed by each arm of the service (primary care, n=91; secondary care, n=81). The time spent reviewing a patient at first assessment can range between 60 and 90 minutes. However, the total time spent per patient case to ensure that needs are addressed can vary dependent on the setting, complexity and solution(s) required.
Demonstrating quality improvements is the key to resilience in a fast changing healthcare environment. Despite this, measuring the impact of LIMOS remains a challenging task. Improving quality has to remain the main focus for medicines optimisation and as such, patient specific outcomes collated include improved patient experience, increased number of patients taking their medicines as intended, reduction in the number of hospital admissions/readmissions associated with medicines, and reduction in the number of incidents of avoidable harm from medicines. Other more direct quantitative measures, such as cost associated with the number of medicines discontinued, reductions in medicines waste, and reduction in the number of social care visits for medicines administration, are also considered. In addition, a patient and user satisfaction survey will go some way in quantifying the value of direct access to experts in medicines. Attributing savings to the various parts of this integrated model is not easy, but is also not necessary, as it is generally accepted that both direct and indirect savings made will be of benefit to the wider health and social care economy.
Conclusion
With limited published data on the structure of a system-wide coordinated care model focusing on medicines optimisation, LIMOS describes an approach that goes towards addressing an identified gap in meeting the needs of the local population. The essential components described should be explored by other health and social care organisations considering the establishment of a new, or development of an existing, model to support medicines optimisation.
Key messages
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What is already known on this subject
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The management of almost all long term conditions involves the use of medicines, and yet there is a growing body of evidence that indicates between 30% and 50% of patients do not take their medicines as recommended.
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Despite this there is limited published data relating to the establishment, structure and operation of system-wide coordinated care models across the interface focusing on medicines optimisation.
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What this paper adds
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This paper describes an approach in addressing an identified gap in meeting the medicine support needs of the local population. The Lewisham Integrated Medicines Optimisation Service provides a formal pathway for the referral of patients with medicines-related problems for assessment, support and follow-up to review access, adherence and clinical issues.
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Enablers underpinning successful service delivery are also described, including the ability to share information and refer across traditional boundaries to ensure that patient-centred care is delivered together with the implementation of a joint health and social care medicines policy.
Acknowledgments
We are grateful to Michelle Hoad, who provided support integral to the development of the policies jointly agreed with social care. We also particularly thank Lewisham Social Care leads whose engagement with underpinning work streams is vital to the success of LIMOS. Ongoing thanks also go to Lelly Oboh for her generosity in sharing resources, in addition to her knowledge and experience along the timescales of our medicines optimisation projects.
Footnotes
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Contributors KL, KH were involved with drafting the paper and revising it critically for important intellectual content. CB, MS were involved with revising it critically for important intellectual content
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Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed.