Polypharmacy & mindful prescribing Alpana Mair Therapeutic Partnership Lead

1. Polypharmacy & mindful prescribingAlpana Mair Therapeutic Partnership Lead

2. Multimorbidity in Scotland-Would require an extra £3.5 billion 2031 62% projected rise in over 65s 2006-31 144% projected rise in over 85s 2006-31 Increased prevalence of LTC, esp COPD and Diabetes 24% projected rise in older people admitted as emergencies by 2016 Audit Scotland Mercer, Guthrie, Wyke: Scottish School of Primary Care

3. Increase in polypharmacy Pr. Bruce Guthrie, Dundee

4. Multidisplinary across Health boards with Patient Representation • Model of Care • Materials to Aid Decision Support and Person Centred Information • Identification of Patients and Data for Improvement • Engagement and Infrastructure to Sustain Model

6. Who is the guidance for? • Health boards to inform how best to deliver • Tools are for health boards to put into a pack for clinicians • Advises on what is currently delivered under QOF- Med level 2

7. Which patients to target?- iSPARRA • Patients that have a 40-60% risk of admission in last 12 months • Over age 75 • Taking 10 or more Medicines in BNF categories including a High Risk medication • In a care home • Then 65+ or 5-9 BNF Categories

8. Drug Review Process- A4 summary with links

9. NNT and NNH- drug effectiveness tables • The ‘Number Needed to Treat’ (NNT) is a measure used in assessing the effectiveness of a particular medication, often in relation to reduction in risk over a period of time. The NNT is the average number of patients who require to be treated for one to benefit compared with a control in a clinical trial. • ‘Number Needed to Harm’ (NNH) is a related measure which is the average number of people exposed to a medication for one person to suffer an adverse event

10. Highland Tayside Lothian Forth valley Multidisplinary approach GP, Pharmacist, Geriatrician Outcomes so far…..

11. Data Collection and evaluation • Number of patients reviewed from list given by iSPARRA and CHI numbers • Number of high risk medications stopped and why • Medications started • Cost benefit

12. Next Steps 1. Guidance document will be reviewed after 6 months for revisions June 2013 2. Development of iSPARRA to help track changes in medication and potentially other health outcomes 3. Development of indicators as PIS data develops 4. Development of coding for polypharmacy reviews nationally 5. Analysis of Scotland wide data for Polypharmacy 6. patient tools to help them actively take a role in polypharmacy reviews 7. Development of tools for the clinicians undertaking polypharmacy reviews 8. Development of IT systems to enable extraction of data from GP prescribing systems by national read codes.

13. Patient Engagement‘Safe to ask’

14. Authoritarian Physicians And Patients’ Fear of Being Labelled ‘Difficult’ Among Key Obstacles to Shared Decision Making D.L. Frosch et al Health Affairs May 2012 Vol 31 no.5 1030-1038

16. If you’re not part of the solution then you are part of the problem….

17. “When you confront a problem you begin to solve it.” Rudy Giuliani

18. Lack of a shared mental model? ‘Given additional pain killers and not explained why’ ‘I am still not sure about the medicine I am taking’ ‘Given the wrong drugs to take home’

20. Improve Understanding • What you are taking • Why you are taking it • When you should take it • How you should take it • How long you should take it for

21. Who needs to ask questions? • Doctors, Nurses, Pharmacists and other healthcare professionals. • Why? • Don’t they know what I take? • Patients • Why? • What if I forget to ask when I see the doctor?

23. Make it easy

25. “Good ideas are not adopted automatically. They must be driven into practice with courageous patience” Hyman Rickover Jennifer.ross@nhs.net @med_safety_bird

26. 180 day Rapid Cycle Improvement Project in Medicines ReconciliationDr Gregor Smith

27. One man may hit the mark, another blunder; but heed not these distinctions. Only from the alliance of the one working with and through the other, are great things born. Antoine de Saint-Exupery

28. Background to 180d RCIP • Commissioned by the Quality Alliance Board • Five Boards (NHS Lanarkshire, Tayside, Highland, Grampian and Forth Valley) • Aims: • Build on and accelerate the work in med rec • Improve breadth clinical engagement • Share learning between and beyond participating Boards • Develop capacity and capability for rapid cycle improvement work

29. Admission Current medicine list (using 2 or more sources) Plan Demographics Allergy Status Accurate Cardex Discharge Current medicine list Documented Changes Demographics Allergy status Accurate interim discharge letter Project Measures

30. Medicines Reconciliation: Definition The process of obtaining an up-to-date and accurate medication list that has been compared with the most recently available information and has documented any discrepancies, changes, deletions or additions resulting in a complete list of medications accurately communicated

31. Project Structure and Process • 3 phases: Scoping and Planning, Testing and Improvement, Implementation and Assurance • Weekly / bi-weekly calls • Milestone meetings • Strong links with Medicines Reconciliation Network and hosting on their Community Site • Problem sharing / solving; developing test strategies; reporting and spreading successes or challenges

32. High compliance with 2 source reconciliation and formation plan Project Pause over Festive holiday Changeover junior medical staff: reduced access to ECS Reduced use of ECS in 2 source reconciliation Consultant spread and junior audit Introduction of new cardex Ward round pause; MDT rounds; IDL audits Consultant engagement

33. Potential correlation between reduced use of ECS and Accurate Medication History

35. Learning and Recommendations • Education and training • QI capacity and capability • Professional Leadership • Clinical Quality Strategies • Consultation • Process and System Solutions • eHealth • Workforce

36. Sustainable Safe, Effective, Efficient and Person Centred care associated with medicines requires a multi-professional approach

37. Acknowledgements Alexa Wall, SPSP Fellow, NHS Lanarkshire Jane Ross, Improvement Advisor, HIS Susan McGaff, Policy Officer, HIS Jennie Ross, NHS Grampian Dr Alison Graham, NHS Lanarkshire Jason Leitch, Clinical Director, Quality Unit Dr Anne Hendry, National Quality Lead Carol Sinclair, Better Together Programme And participants from all the Boards for their patience, diligence and innovation Gregor.smith@lanarkshire.scot.nhs.uk

38. Discussion Questions • What examples of improvement work relating to medicines are you involved in with your organisations? • What gaps in the care related to medicines have you identified? • What approaches might NHSScotland take to accelerate improvement in the care associated with medicines?