Multidisciplinary Review of Medication in Nursing Homes – A Clinico-ethical Framework
Northumbria covers one of the largest geographical areas of any health trust in England and provides integrated health and social care to over 500,000 people living in Northumberland and North Tyneside and employs 9000 staff.
Medicines use in care homes is an area of concern. Problems include:
- Excess medicines (sometimes inappropriate)
- Lack of structured review of medicines
- Patients unaware of what treatment they are on and why
It is estimated that between 10% and 71% of elderly patients take medicines that are not suitable or have the potential to cause harm. Some patients experience minor side effects from medicines that have a profound effect on their quality of life.
Case study: 85 year old lady in a care home was bedbound (strokes & dementia) and unable to communicate or make decisions for herself. She was prescribed 11 regular medicines, including medicines to prevent a fracture, and medicines to prevent cardiovascular disease. Each day nursing staff would administer these medicines by lifting her head and pouring the solution into her mouth. This lady was also taking antidepressant, hypnotic and antipsychotic medicines for agitation. On stopping her preventative medicines her agitation resolved and in time her clinicians were able to stop medication for her agitation.
This case study demonstrates that residents are prescribed excess, inappropriate medication and they or their families (advocates) are not given any say in what medicines they are given.
The aim of this project was to develop a patient involvement framework for medication reviews in care homes.
Funding from The Health Foundation Shine 2012 award was used to set up a series of medication reviews in care homes. A team involving psychiatry of old age, pharmacy, care home nurses, general practitioners and the Trust’s patient experience expert led the project. Care home and general practices from North Tyneside were invited to participate. The stages of the reviews were as follows:
- 1. Detailed medication review by clinical pharmacist
- 2. Multidisciplinary team (MDT) meeting to discuss review
- 3. Meeting with resident or representative (e.g. family) to discuss medicines, MDT discussions and patient’s preferences
- 4. Proposed changes (e.g. stop or start medicines) take into consideration the MDT and resident (or representative) discussions
As not all residents had the mental capacity to participate in the reviews, the team developed a four level patient involvement framework, with all reviews starting at level one and moving down to level four (least desired option).
- 1. Resident involved in review and makes decisions regarding medicines
- 2. Resident has no capacity: Family or representative makes decisions on behalf of the patient
- 3. Family not actively involved in resident’s care: A letter sent to family outlining the discussions from the MDT. The family are encouraged to contact the pharmacist to discuss or challenge any proposed changes
- 4. No family or other representation: Formal advocacy
The residents are followed up periodically following any changes to monitor for any adverse events. The project’s patient experience lead has been interviewing a sample of patients and family members to capture their experiences on being involved in this project. We used a mixture of quantitative data and qualitative data to measure the success.
To date we have completely reviewed 105 residents in 5 care homes.
Quantitative data was collected prospectively at the end of the review process. Our primary data sources are GP records, MDT data collection form and care home records. In some cases we have requested hospital notes.
In 105 residents we made 364 interventions with 14 different types of interventions being made. The most common intervention was to stop medicines; 195 medicines (23.6% of all medicines prescribed) in 81 residents (77%). The 105 residents were taking 825 medicines (average of 8 per resident) compared with 630 medicines (average of 6 per resident) following the review; a 23.6% reduction in medicines burden. The main reason for stopping medicines was lack of indication for the treatment; 108 (55.3%) residents. In 16 cases (8.2%), patient safety was the primary reason for stopping the medicine.
Resident Involvement Framework
Figure 3 shows our current resident involvement mapped against the framework. In most cases the residents or their family representative were involved in decisions. We have used advocates for two residents.
Figure 3: Resident Involvement Framework
The main themes emerging from care home staff are:
- Non-compliance, inability to take tablets, residents’ lack of awareness and understanding of current medication.
- Staff reported varying involvements from family members
- Suggestions to improve their residents’ experience of medication and medication reviews included regular medication reviews prompted by the medical practice, forgetting the cost implications of liquid medication when a resident requires it, protected medication rounds and prevent wastage of drugs that have not been removed from repeat prescriptions.
Family members valued getting a voice:
“There is no point in people being on things unnecessarily. You don’t need to be on them, why be on them”
“I think we should be notified if something was going to be stopped. [pharmacist] discussed about taking her off a Statin. Erm…. but at the minute I think she is happy and has really good quality of life, I don’t think she should be taken off things without consulting the family…”
General practitioners agreed with involving patients in decisions about medicines:
“I think involving the family is a really good idea……………it is a positive thing to try and involve them”
The project has attracted interest from primary care and locally there is a desire for it to continue post-Shine funding. A number of initaives are underway to ensure this happens:
- 1. North Tyneside Clinical Commissioning Group (CCG) were informed of the project and have received regular updates from the Trust’s communications team. We are curently working with the CCG on a business case to expand this review service from April 2014, when funding ends.
- 2. Northumberland CCG have met with the project team and negotiations to set up a similar service in Northumberland are ongoing.
- 3. Northumberland medical practices have shown interest in this project. One practice has commissioned services from the Trust to run reviews for their care home residents and we are about finalise a commission from a second practice to provide a similar service.
The learning from this project has been used to shape a local service suppporting older patients in their own homes.
This initiative has the potential to be applied to other patients in care homes. We have already shared our findings with a team in another CCG who are planning a similar initiative. We have developed a model of patient involvement that other individuals working with care home residents can use.
Our work has the potential to be transferred to housebound elderly patients who live in their own homes. Many of these patients have the same medicines issues as residents in care homes, taking multiple medicines with little involvement in decisions. We have been sharing our work with a local team of health and social care professionals (North Tyneside High Risk Patient Programme) so that learning from this care home project can be transferred to patients in their own homes.
The novel aspect of this project is the patient involvement framework. Too often patients in later life or those who lack capacity to make decisions do not get a say in what medicines they take or don’t take. This project allows patients or their representatives to make informed decisions by being supported by a team of health care professionals.
An example of this in practice is a case of a 92 year old lady who was prescribed simvastatin tablets at night. She was unsure what this was for. After the indication (prevention of cardiovascular disease) and the risks/ benefits had been explained, she made a decision to stop taking this medicine; a decision that her GP and other health professionals supported.
An important learning point from this project has been not to assume that as a health professional, one knows what is best for one’s frail older patients. Patients (and their families) have a desire to be involved in decisions about them.
We have used shared decision making tools to help supports residents and their families with decisions about starting, changing or stopping medicines.
Cate’s plots: http://www.nntonline.net/visualrx/cates_plot/
NHS Right Care: http://www.rightcare.nhs.uk/index.php/shared-decision-making/
Health Foundation’s MAGIC programme: http://www.health.org.uk/areas-of-work/programmes/shared-decision-making/
The team have a number of flyers, research posters, data collection tools (including database), patient/family/professional questionnaires that we will be happy to share with anyone wishing to undertake similar work.