Safer prescribing in frailty and empowering independence in older people

1. Safer prescribing in frailty and empowering independence in older people Sujo Anathhanam Megan Humphreys academy@yhahsn.nhs.uk / 01274 383966 www.improvementacademy.org

2. #WeStopMeds

3. Polypharmacy: the problem • 1/3 of ≥ 75 year olds are taking at least six medicines. • 6%of admissions to hospital are drug related. • 50% of medicines are not taken as prescribed.

5. APPROPRIATE POLYPHARMACY “Prescribing for an individual for complex conditions or multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence” PROBLEMATIC POLYPHARMACY “Prescribing of multiple medicines inappropriately, or where the intended benefits of medications are not realised” King’s Fund, 2013

6. Aims • Reduce inappropriate prescribing for older people living with frailty • Inappropriate prescribing defined as: • unnecessary (without indication or benefit) • unwanted (by the patient) or • unjustifiable due to its risk/benefit ratio. • In primary care

7. Methods • 12 independent GP practices in 5 CCGs within Yorkshire • Moderate or severe frailty by eFI • Conversations in surgeries, home visits and care homes • Training package

8. Project Teams

9. Our approach

10. The Tools UK Polypharmacy Guidance from: NHS Scotland, Kings Fund, NHS Wales, PrescQIPP NHS Programme Evidence-based tools: STOPP/START tool 7 Steps approach No Tears tool Medicines Appropriateness Index

11. Project Timeline

12. Average number of items on repeat prescription

13. Outcomes in Primary Care • We identified and addressed barriers to changing prescribing behaviours. • There was a 6% reduction in prescriptions per person, • The conversations with patients were reshaped. • Attitudes to prescribing for people with frailty changedimproving the culture of care.

14. Quotes “The work is worthwhile as a lot of these patients are missed due to being home visits and not likely to come to surgery for reviews or follow ups.” GP “The most important part of the project is the legacy it has left” GP “I hadn’t fully appreciated the size of the problem nor the barriers to change” Project team

15. The future Spread We are designing a model for spread:-Define a manageable sized cohort.-Analyse practice barriers to reducing medication burden.-Use the tools that have been shown to work to overcome barriers.-Measure the improvement.-Supported with facilitation Opportunities GP contract Health Education England GP trainers North Yorkshire CCGs AHSN network – Flagship frailty project Practice to practice SPS repository for NHS England Connected Health Cities

17. The idea • Self-management support interventions not routinely available for older people living with frailty • Feasibility of joint working between primary care and voluntary sector

18. Intervention delivery • Eligible people were: • over 65 years • at risk of mild frailty using eFI • high users of primary care. • Invitation letters sent out by the practice. • Offered consultation with an Age UK Supporting Self-Care coordinator

19. Service provision • Guided conversation • Motivational interviewing techniques • Individual plan agreed • Further support and signposting to local services where needed

20. Results: take up • 168 people were offered the intervention • 108 expressions of interest • 106 people took up the offer • 52% female; 48% male • No significant differences between those who took up the intervention and those who didn’t

21. What did the offer look like?

22. Sign posting & support • Age UK services: • Advice & support • Help at Home • Befriending • Aged Veterans • Walk from Home • Independent living centre Local Healthy living charity & Social Prescribing team Local clubs & groups Local Authority Falls prevention Weight management Alzheimer's Society Online support & IT skills Audiology Dental Health

23. What did staff think? “Some patients were already looking after themselves; may have been better received by the moderately frail” Advanced nurse practitioner “Very proactive exercise for staff to work with Age UK. We have enjoyed the opportunity and hope to continue these relationships beyond the completion of the project” Practice manager “An initial consideration was how the integration between the voluntary and community sector and primary care teams might work but this has been a success rather than a barrier … information governance systems could perhaps be re-examined” Age UK coordinator

24. What did patients think? “I came away feeling confident” “I felt encouraged that someone cared” “Just knowing that there is someone there and how to get in touch with them is a great help … it’s nice to know what is available if we do need it but we don’t feel like we need any help in any particular area at the moment “I was pleased to be chosen, glad to be asked … surprised that with all the cost cutting the practice was able to offer this service”

25. Findings and next steps • Refinement of target group • Data being analysedregarding primary care utilisation and patients’ self-rated self-care ability • Resource would be needed to support administrative aspects • Joint working between primary care and voluntary sector is feasible

26. Contact Details @Improve_Academy @AHSN_YandH @ImprovementAcademy www.improvementacademy.org www.yhahsn.org.uk t: 01274 383966 e: academy@yhahsn.nhs.uk