Knowledge and Capability Guide COVID-19 Care Homes Training Resource A U G U S T 2 0 2 0

This guide is focused on developing the underpinning knowledge and understanding of care homes pharmacy practice to support the delivery of care during the COVID-19 pandemic. Other domains of practice that are also critical when practising effectively at Foundation and Advanced levels are set out in the respective clusters of the RPS Foundation and Advanced Pharmacy Frameworks, and the soon to be published APTUK/PCPA National Competency Framework for Primary Care Pharmacy Technicians.

When using this self-assessment tool, members of the pharmacy team should take into account their individual workplace responsibilities and role limitations. This tool supports an individualised approach to training with each learner having different knowledge gaps and learning needs. Further detail regarding core responsibilities of pharmacy professionals in care homes can be found here.

Using the Guide• Refer to Step 1 and Step 2 of this training resource.• When self-rating your confidence against a topic (1-5), 1 = Not confident at all, 5 = Very confident• Practice in your workplace may vary from the views outlined in the webinars. Make sure that you know where to find

local guidelines and work within these• RPS website links: Log in to rpharms.com before clicking on these to access the page more easily

Topic prioritisation

H I G H Relate to the immediate needs of care homes and their residents during COVID-19. All learners should cover these in their workplan.

M E D I U M Important areas of practice during the pandemic that are less acute. All learners should cover these in their workplan after the high priority topics.

L O W Common in the care home setting, but less important in the context of the pandemic. Learners can cover these if there is capacity to do so.

For the most up to date version of this guide click here

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1 Systems and ProcessesFamiliarise yourself with the local context: • Levels of care / resident case-mix • Roles and responsibilities of the MDT within the care home and also within local professional networks - see ‘Getting to know your team’• Medicines management processes (e.g. storage, supply of routine repeat and acute medicines, end of life medicines and out of hours requests)

- if there are processes that need to be developed, see these examples from Buckinghamshire and Devon CCG • Local IT systems - e.g. nhs.net• Local clinical governance structures and processes• Local funding arrangements e.g. NHS Directed Enhanced Service (DES) contract

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Follow Infection Prevention and Control procedures when providing services during COVID-19

Note: Requirements will depend your local context.PPE• Recommended PPE for primary care and

community settings - PHE• How to use PPE, see instruction video – GOV.UK• RPS FAQ on PPE

General IPC• DOH summary for care homes

Handling medicines & charts:• NHSE/PHE guidance

Work with care home staff to implement safe and effective processes for requesting, prescribing, supplying and administering medicines during COVID-19

Overview: • Managing medicines in care homes - NICE –

sections 1.9, 1 .10, 1 ,11 , 1 .14• PrescQIPP guide (pages 1-4)• Change to see RPS FAQs on prescription services,

repeat prescriptions, delivery services.

eRD• NHS BSA COVID-19 guidance• Wessex AHSN webinar

MCA/MDS• PrescQIPP guidance• COVID-19 FAQ - Pharmacy services MCA during

COVID-19

Ordering and prescribing• Bulk prescribing (PrescQIPP)• Ordering instructions for EMIS, and SystmOne• Ordering medication by proxy (Digital Primary

Care - see instructions here)

OTCs and homely remedies (CQC)Refused or missed doses – PrescQIPP guidance Administration and record keeping – NICE quick guide• Direction to administer forms & use of electronic

signatures (SPS)• Guidance for amending/consolidating dosing

times (SPS)

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Ensure practice within the care home is in line with legislation and standards, including implementation of changes during COVID-19 e.g. controlled drugs

Controlled drugs• Guidance (PrescQIPP)• Contingency legislation during COVID-19• Storage in care homes during COVID-19 (CQC)• CD Reporting page

Safeguarding• It is expected that you have completed the

necessary learning and assessment

Shortages• See the RPS FAQ

Mental Capacity Act and covert administration• NICE Quick Guide - giving medicines covertly• Mental Capacity Act at a glance (SCIE)

Administration of medicines by care assistants• GOV.UK guidance

MCAs, delegated tasks, access to medicines• CQC informationMedication-related incidents• Identifying, reporting and learning (NICE NG5)

Advise on measures to minimise drug wastage e.g. quarantine, reuse of medicines

RPS FAQ – reusing medicines and accepting returned medicines

Advise on appropriate management of patients’ own drugs (PODS) in the context of the pandemic

PrescQIPP guidanceManaging medicines in care homes - NICE - 1 .13

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Systems and Processes Continued.. .

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2 Clinical Review & AdviceFamiliarise yourself with the following in your care home: • Clinical records and forms, such as change of medicine forms (see example), MAR charts, and fluid charts.

This CPPE e-course unit is also helpful: 5.3.6 Care home daily assessment tools (registration required – see instructions)• Home rounds - how and when are they run, who is involved and what is their role, forms or templates that are used• Access to resources, e.g. MedicinesComplete – see access instructions• Care planning and Comprehensive Geriatric Assessments (CGA) - how these are delivered• Adjustments to how medicine support is being provided during COVID-19: check what adjustments are being made locally, e.g. Microsoft Teams

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Prioritisation

Prioritise care home residents for review and management in the context of COVID-19, including those who are acutely unwell, complex or at high risk residents, new or transferred residents,

1 . Acutely unwell or deteriorating• RESTORE-2 tool for identifying deterioration• The NEWS2 score has also been used, you can

also read about its application in the care home setting.

• Significant 7+ resource• Sick day rules – Find the link for general

recommendations and in diabetes on the PCPA hub (scroll down to April 2020)

2. Complex or high-risk residents• Case finding indicators to prioritise review• Identify frailty - Top tips, Clinical Frailty Scale• Falls risk screening tools

3. Prevent hospitalisation• Risk factors - conditions – see pages 17-18 of this

report• Prevent exacerbations of disease and target

high risk drugs - see pages 4-5• Vaccination good practice guide (BGS)

4. New or transferred care home residents• see medicines reconciliation topic

5. Medicines that require monitoring• SPS guidance

6. Other priorities• New symptoms, adverse event i.e. recent fall or

allergy/drug reaction

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Clinical review

Provide medicines reconciliation in the care home setting, resolving queries, errors and omissions at transfer of care

Basics:• Medication reconciliation guide (NPC) – pages

11-13, 16-19• CPPE Medicines Reconciliation (more in-depth)• Communication requirements when transferring

between settings (NICE NG5)

Considerations for care homes:• Recommendations for care homes (PrescQIPP)• Challenging situations for medicines reconciliation

(AHRQ)• NICE quick guide for transitions of care• Discharge summary record - useful indicator of

information too look for

Use a structured process for clinical review to prioritise, identify and resolve medicines related issues in the context of the COVID-19 pandemic

(Download the Consultation and Review tool)

Definition of a Structured Medication Review:• NICE guidance NG5 section 1.4• 6 priority areas for clinical support

have been identified during COVID-19

Prioritisation of interventions during COVID-19• UOM Recommendations - please note this

resource is from the USA.

Prevent and address problems:• Bleeding, falls, confusion, and metabolic

disturbance - STOPIT tool • Dehydration (Wessex AHSN), pages 6, 9, and 11• ADR drug table

Potentially inappropriate medicines (PIMs) screening tools:• Aged 65 and over - STOPP/START screening tool • Frail with limited life expectancy - STOPPFrail tool

(page 4) • By Medicine or BNF chapter (NES Polypharmacy

online tool or mobile device app)• Anticholinergic drug burden scores (insufficient

evidence to recommend one over another): ACB calculator, Medichec (AEC score), Anticholinergic Risk Scale

Other resources:• SMR webinars: SPS 2/7/20 • Pharmacokinetic and pharmacodynamic changes

with aging – consider when reviewing doses • Example of strategy to identify candidates for

review

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Clinical Review & Advice Continued.. .

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Deliver person-centred consultations (remote or face-to-face), encompassing:Shared decision making with residents, carers, and the wider MDT, medication adherence.

Taking multi-morbidity into account• NICE NG56 sections 1.5 and 1.6

Shared Decision Making• BRAN model• Database of treatment benefits/risks to help

support your conversations• Three-Talk Model for SDM, see full article

if interested• SDM in dementia and frailty

Communication• Communication tips for the older patient – NIH• Managing delirium during COVID-19 (CEBM) - see

Box 2 for communication guidance when using PPE and Box 3 for remote consultations

• RPS Remote Consultations hub• Example pharmaceutical care plan

template for residents.

Involving the MDT in reviews• PrescQIPP guidance document, especially from

page 4• Example of how to communicate with GP about

medication reviews

If you need a more in-depth refresher: CPPE have a e-learning course on clinical history taking, including red flag identification.

Medicines information and advice

Deal with medicines-related queries from residents, carers and colleagues

How to answer queries:• UKMI recommended resources

Common queries:• Medicines Complete (including Drug

Administration Via Enteral Feeding Tubes )• Considerations when crushing tablets or opening

capsules (SPS) • Supporting patients with dysphagia• Medicines Information for Adult Social Care

Providers during COVID-19 (CQC)

Signpost appropriately to relevant local / community services

• Regional MI contact details (SPS)• SPS advice and support recommendations

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Clinical Review & Advice Continued.. .

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3 Managing Medical ConditionsFamiliarise yourself with the following local context:• Local formularies – e.g. pain management, end of life and antimicrobial prescribing policies• Pathology services• OPAT/Hospital in the Home services• Any other relevant ancillary or medical support services

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Frailty and multi-morbidity • BGS Fit for Frailty - see the summaries on recognising and managing frailty

• NICE CKS Multimorbidity• Podcast on managing falls

End of life and palliative care, including Hydration / SC fluids

• Quick overview (CQC)• Palliative care formulary – via MedicinesComplete• SPS COVID-19 hub• Example prescribing and communication

templates for symptom management• Last days of life and frailty summary (BGS)

Prevention and management of Delirium during COVID-19

• One-page summary (SIGN guidance)• British Geriatric Society delirium during COVID-19

guideline• PINCHME mnemonic (BGS)• Podcast on delirium

Deconditioning, myopathy and nutritional needs post COVID-19

• BAPEN guidance for identifying malnutrition during COVID-19

• PCPA podcast part 1: overview and role of the pharmacist

• Frailty in end of life - dysphagia and nutrition summary (BGS)

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Management of COVID-19 positive residents, including clinical trials if participating

• Poster summary (NHS CGC)• British Geriatric Society COVID-19 in care

homes guideline• Be aware of the atypical presentations of COVID-19

in the elderly• Therapies, clinical trials and testing

(RPS COVID-19 hub)

Bacterial infections, including:• Acute cough• Pneumonia• Infective exacerbation of COPD• UTI, including recurrent• Skin and soft tissue infection,

including cellulitis, and diabetic foot infections

NICE antimicrobial guidelines (where local protocols are not available): • Note that community acquired pneumonia

guidelines are currently superseded by this COVID-19 rapid guideline

• PHE UTI flowchart for adults >65 years and CPPE UTI factsheet

• CPPE Sepsis factsheet

If you are not familiar with Antimicrobial Stewardship, see this CPPE e-learning and be aware of the TARGET toolkit.

Asthma and COPD • SPS COVID-19 hub• Modifications to usual care during COVID-19• Inhaler technique (including videos) - RightBreathe• NES polypharmacy tip - theophylline• Home oxygen explained (NHS) and SPS links• Management in care homes (CQC),

Dementia • CPPE fact sheet• Key messages during COVID-19 (SCIE)• MATCH-D tool - principles for medication use for

co-morbidities (by dementia stage or in general)• Communicating with people with dementia (NHS)• New diagnosis quick guide• Decision aids: antipsychotic use for aggression

Diabetes • PCCSUK COVID-19 Learning Bite 2 – Diabetes• Note the difference in NICE/QOF indicators when

applied to frail residents• Insulin passports• COVID-19 Management of Diabetes in Care Homes

Managing Medical Conditions Continued.. .

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AF including stroke prevention and anticoagulation

• PCCSUK COVID-19 Learning Bite 1 – Managing anticoagulation in AF, or see the full guidance

• ESC – Rate and rhythm control in the elderly• NES Polypharmacy tips - Amiodarone. digoxin,

beta-blockers, calcium channel blockers

Coronary heart disease (CHD) and heart failure

• PCCSUK COVID-19 Learning Bites 5 and 6 – Heart failure and CVD risk management

• NES Polypharmacy tip - antiplatelets, diuretics

Chronic kidney disease • CPPE Fact Sheet• KidneyCare UK guidance• NICE COVID-19 rapid guideline

Mental health – anxiety, depression, bipolar disorder

• CMHP Quick Reference Guide: Acute Psychiatric Presentations

• CMHP: Managing long acting antipsychotic depot injections during COVID-19

• NES polypharmacy tip - antipsychotics• Psychological support in end of life frailty (BGS)• RPS/CMHP Q&A webinar• NICE guidance and case studies

Pain • End of life care in Frailty: Pain (BGS)• Guidance on the management of pain in older

people – see pages 8-11 (Pharmacology)• Opioids – clinical use and practical tips

(Opioid aware)

Managing Medical Conditions Continued.. .

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Rheumatoid arthritis • SPS COVID-19 hub

Parkinson’s • CPPE Fact Sheet• Consultation checklist, apomorphine guidance,

and more - Parkinson’s UK

Hypertension • PCCSUK COVID-19 Learning Bite 3 and 4 – Assessing and treating hypertension

• NES Polypharmacy tip - calcium channel blockers• Note the difference in NICE/QOF indicators when

applied to frail patients

Constipation and incontinence • CPPE Fact Sheet - Constipation• NES Polypharmacy tip - antimuscarinics, laxatives• Incontinence - summary of causes and

management (BGS)

Managing Medical Conditions Continued.. .

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Osteoporosis • CPPE Fact Sheet• NICE guidance for fracture prevention – when BMD

testing is recommended keep in mind that this may not be feasible during the pandemic

• Patients who are already on bisphosphonates and denosumab – NICE COVID-19 guidance

• Vitamin D advisory statement during COVID-19

Ulcers and wounds • CPPE Fact Sheet – Wounds• BNF Wound management section – see advanced

and antimicrobial wound dressing sections for information on appropriate use

• AHSN information hub

Managing Medical Conditions Continued.. .

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Additional learning: The following in-depth resources are available to support your ongoing development, but are not essential to complete prior to working in the care home setting during the pandemic:

• CPPE primary care essentials e-learning• CPPE Safe process for medicines optimisation in

care homes – see Book 1• CPPE clinical history taking – what a good

consultation looks like• Medication use in care homes – Course 1, 2 and 3

(PrescQIPP)• CPPE Consultations with patients with dementia

and frailty• CPPE Consultations with mental health patients• Consultations for anticoagulation and AF • Reducing antipsychotic use in dementia (PrescQIPP)• Administering medicines covertly (NICE webinar)

I N S T R U C T I O N S F O R A C C E S S I N G C P P E P R I M A R Y C A R E E S S E N T I A L S E - C O U R S E

1 Register with CPPE 2 Go to the e-course and click ‘Book a place’ 3 Accept the terms and conditions, you will then be

emailed a course invitation from Canvas Free for Teachers - notifications@instructure.com

4 Accept the invitation and log into canvas. - click on the ‘module’ button on the left-hand side of the screen to see the contents page and find the unit that you would like to access

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