In response to the COVID-19 Hospital Discharge Service Requirements, we have adapted our established medicines optimisation in care homes (MOCH) service to provide direct, onsite support to a new step-down unit set up within a care home by the local CCG.
In this blog, our Norfolk and Waveney MOCH pharmacist team outlines the key elements of the service, how our pharmacists are working as part of a multidisciplinary team and the elements we feel are crucial to providing a successful and safe service to support those coming into and leaving the step-down service.
The new service allows for up to 27 beds to provide step-down discharge support for patients from local acute trusts awaiting packages of care to go home or onto further placement when available.
An MDT is in place to support the care of these patients and their safe onward discharge. The team includes care home staff, continuing healthcare nurses, occupational therapists, physiotherapists, pharmacists, social workers and advanced nurse practitioners.
NHS Arden & GEM Commissioning Support Unit provides the pharmacy support within the home, consisting of three clinical pharmacists on rotation, with two on shift most weekdays including bank holidays. Our aim is to minimise the additional pressure on care home staff by ensuring quality and safety in all aspects of medicines, including supporting patients in what can be challenging circumstances. Our responsibilities include (but are not limited to):
- Medication reviews
- Medication ordering, weekly audit and stock check
- Patient consultation and medication counselling prior to discharge from the unit
- Support care home staff with medication queries, streamlining processes and ensuring sufficient supply
- Liaison with acute trusts and community pharmacists
- Completion of clear documentation of any medication changes that occur within the unit
- Assisting in assessing patients who wish to self-administer medication.
Tackling new challenges:
Care home staff in this unit are having to deal with a much higher number of admissions and discharges than would normally be the case. An MDT approach is needed to ensure the safe administration of medicines to patients during this high turnover rate.
All medicines have to be checked in, counted and aligned with medicine administration records (MARs) so the home can account for stock. We book in medication when it arrives with patients and complete MARs and other necessary paperwork. We also liaise with acute trusts to discuss any discrepancies with the discharge medicines. We have so far worked with a variety of acute teams including ward staff, pharmacy, dietetic and diabetic teams to resolve clinical queries.
Patients themselves often need support to understand their medication and how and what they will need to take post discharge from the step-down unit. This is an unusual step for care homes but it’s an area where we’ve seen a real benefit of having clinical pharmacists involved. Medication reviews conducted in consultation with the patient’s usual GP have, in some cases, led to deprescribing unnecessary medicines. We’ve also been able to swiftly and safely resolve confusion where hospital discharge information and the medication regime issued for the patient do not match. Being on site has enabled us to act quickly and provide reassurance to patients.
The discharge process has been a huge area of development for our team as this is a really unusual aspect of working with care homes. We want to make sure it can be completed in a timely but safe manner, so had to develop a process to ensure all medication is discharged with the patient. We also liaise with the local pharmacy supplying the unit to prevent further medicines being sent to us following discharge to prevent wastage. Any changes in medication are accurately collated and shared with GPs, community pharmacists and carers as appropriate. This ensures any changes made following discharge from hospital are properly recorded and maintained to enable safe administration once the patient arrives at their onward destination.
Integrated working across care settings
Two key elements to this model working effectively are the MDT and the integrated working across care settings.
From our team’s perspective, working closely with other specialists has improved the experience for us and our patients. For example, we are able to support physiotherapists assessing patients’ stability with information about medicines which can contribute to a risk of falls. We are also working directly with the social care team to ensure medicines can be safely obtained and administered once the patient goes home or to their next care setting. Where obstacles have arisen due to delays in medication or dispensing tools, we have been able to work together to find solutions to avoid delaying discharge, while maintaining quality and safety at all times.
We are also able to relieve the pressure caused by fast discharge and new medicine regimes, whether that’s liaising with acute trusts to fill in any gaps in medication or working with community pharmacists to understand their capacity and plan ahead so they are not overwhelmed with new medication demands once a patient leaves the step-down unit. We recently helped a patient who did not have English as their first language by creating a simple medication chart, including times of day, in their native language, and finding a local pharmacist who spoke their native language who could support them on their return home.
Essentially, this is about communication and understanding the contribution each specialist can make to the overall care of the patient. It is an evolving process and we are learning what works well or needs adapting as time goes on. To support this, we have fortnightly governance meetings to discuss issues that have arisen. An open and honest culture is encouraged so everybody feels they can contribute to suggestions of how our work could be done differently. These suggestions have led to the provision of relevant training where it was felt to be needed by the whole team working on the floor, whether clinical or not, such as in diabetic care and in spotting signs of deterioration. As a result, everybody feels they can contribute to improving the care of individual patients
What happens next?
The need to free up hospital beds during COVID-19 has, as anticipated, put greater pressure on the care home system. However, working in this intensive and more integrated way has enabled us to provide a holistic service to patients and minimise the risk of medicines errors despite a significant increase in the number of discharges, from hospital to step-down, and onwards to home or other care settings. The learning gained from working with other teams has improved our ability to anticipate and plan for likely issues and maintain a safe, effective medicines service.
Working within this unit is novel for the team, but we have worked together to develop this new approach and the learning will continue. Our priority is the safe care of the patients who come to us, ensuring we do the very best by them in these difficult and unusual circumstances. We want to ensure a smooth transition to their own home or next placement. Medicines reconciliation is essential following transfer of care as this is a known high-risk area for medication error, and we have worked hard to minimise those risks with the measures we have put in place.
As the national priority for care homes support gathers momentum at a rapid pace, we are keen to make sure the learnings gained during this project will enable us to support our Primary Care Network colleagues locally with the implementation of the Care homes Directed Enhanced Service. In particular, the direct experience gained working within a multidisciplinary team will be particularly useful give the focus on the MDT aspect of structured medication review (SMR).