Primary care network (PCN) pharmacist Laura Buckley speaks to Joanna Robertson about how conducting medicines reviews in care homes helped her to connect with an often-overlooked group of patients and deprescribe an impressive number of medications.
I thought reviewing care homes would be a good way to get to know my patch.
I'm a primary care network pharmacist, I work across multiple GP practises in the area. I’ve worked in general practice for almost four years, but I’m new to this role.
I have 16 care homes on my patch and as an introductory project, which I felt was a good way of getting to know the practises, it was decided that I would review all patients in all care homes.
It’s quite a significant project because there are hundreds of patients and we have over 450 patients across the patch in care homes and in residential homes.
I often feel like care home patients can be overlooked.
Frailty is a particular area that I'm very passionate about, and I often feel like care home patients can be overlooked. It's a significant area for overprescribing as well. So, I was more than happy to take the project on.
Care home patients are not necessarily the patients that make their own appointments. And a lot, not all, but lots of care home residents have very poor or very fluctuant capacity, which means they're not necessarily as involved with decisions about their care as they could be, or they maybe don’t have the ability to make decisions as easily. It means it can’t always be easy to provide healthcare to these patients.
Having a service that wherein we have a pharmacist that can go in and review these patients with a holistic approach helps ensure that the patient is managed in their best interests.
It isn’t always easy to do that in a practice capacity. Having the opportunity to focus entirely on patients who are in a care home means that you can give them the best opportunity to have their health tailored to their needs in their best interests.
Patient capacity can be very fluctuant.
A patient may not have capacity to make certain decisions but may still be able to tell you things that are important to them.
Understanding patient capacity means understanding to what degree can they make decisions and how can we support them in having the information that's tailored to them so that they can make a decision based on their own understanding.
I feel like I've made a really big difference to patients and care home staff.
I’ve been in and out of 16 care homes in the last three to four months and have seen quite a lot of patients. I feel like I've made a really big difference to lots of the patients across the network and also to the care homes and the care home staff, because they often find that they can't necessarily easily access healthcare professionals to ask for advice.
While I'm in in the home itself – because I physically go into the homes, it's not remote – it means they can come and ask me questions.
I've built a really good relationship with a lot of the staff in the home. So they if I ever go back in now to follow up with residents they me know by name, they know me by face. It's allowed me to build a relationship with the GP practises the care homes and the patients all at the same time.
I take my laptop in, so I've got access to all the patient records.
Medicine is probably one of the last things that I talk about as part of the review.
In the network contract, they are termed structured medication reviews, but for me they are not just focused on medicines.
They are holistic reviews, they cover the patient as a whole and actually the medicine is probably one of the last things that I talk about as part of the review.
I think we need to look at patient capacity, how patients are managing day-to-day, are they coping with the living arrangements? Do they need additional support when it comes to diet, to swallowing, their skin, and are they at risk of falls? What's their mobility like?
I’m very much part of the multidisciplinary team.
If I assess a resident and a decision is mutually agreed with the patient and any representatives that a change in medicines needs to be made, or a referral needs to be made, or something needs to change, then if I feel it is within my professional remit as a prescriber then I will make those changes and document those as part of the consultation into the patient record.
If I felt I needed a secondary input from a colleagues within the multidisciplinary team within the practise, then I would seek a second opinion. It might be that I go and have a chat with the relevant member of staff – perhaps a GP or an advanced practitioner colleague – then then I would do that.
Or if I wanted to make a referral, I could just directly make the referral myself onto secondary care or for more specialist advice.
I’m very keen that community pharmacists be involved with and aware of any medicines changes.
Having been a community pharmacist myself in the past, I know how frustrating it can be to have made the monthly tray up for a patient and to not be aware that a medicine change has happened, and then to find that things have been returned and things aren't quite right.
If changes are being made, especially if it's a reducing dose regime or we’re increasing doses, I often will pick up the phone and contact the pharmacy there and then, at the point of change.
Community pharmacies are very much part of the team and I consider them to be part of my team. So, I would contact them to discuss that and provide them with the rationale for any changes so that they know what's going on.
It also reduces medicines wastage, so they’re not sending out things that they don’t need to send out if something has been deprescribed.
It’s been interesting to see the number of medicines that have been able to be deprescribed.
I think this just shows how much care homes can benefit from a review. We are overprescribing in some areas and certain conditions.
The patients will benefit from a reduced burden of medicines and a reduced risk going forward from polypharmacy.
There’s also a reduced cost in prescribing and a reduction in medicines wastage – for example items that were maybe being prescribed but not being used appropriately or used at all. It reduces the medicines burden across the board really.
The sheer volume of deprescribing I've been able to do has been quite impressive, I think.
I'm really proud of this project.
It's not often that as pharmacists, we turn around and go ‘I'm really proud of that’. But actually, I'm really proud of the project and pleased with how well it's gone.
If you do something you’re passionate about, you will enjoy it.
The better the relationship you have with the care homes the easier it is to do these kind of reviews, and the more support you will get.
I've even had quite a few meals provided for me in the homes which was a complete surprise but it was very nice!
I’d tell other pharmacists considering similar projects to build up those relationships and use opportunities.
And if you have an opportunity to go with a colleague into a care home, whether it's a GP colleague, an advanced practitioner, or one of the nurses, certainly take the opportunity, get to know people and listen to the patients. Patients often have a lot to tell us and we can learn a lot from them.