Managing care for patients with multimorbidities

Patient Led Clinical Medicines ReviewsPresentation to NICE Annual Conference 2018

A novel approachSteve Turner Developed with Elaine Broadbridge (Pharmacist) Mike Thomas (Specialist Nurse)

www.patientled.education@MedicineGovSte #MedLearnsteve@carerightnow.co.uk

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Patient Led Clinical Medicines Reviews TM

1. What are they?

2. How do they work?

3. Related NICE Guidance

4. Evidence to date

5. Challenges in implementation

6. Next steps

7. Where can I find out more?

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1. What does the involve – patients numbers

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1. Linking with an existing project, such as social prescribing, patient engagement, patient & public involvement activities

2. Providing a half day groups session for patients on ‘My Medicines’

3. Offering an optional Patient Led Clinical Medicines reviews session for individual

patients.4. Action research to discover the impact

and outcomes.

1. What does the involve

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1. Linking with an existing project, such as social prescribing, patient engagement,

patient & public involvement (PPI) activities

1. What does the involve

Care Right Now CIC

1. Linking with an existing project, such as social prescribing, patient engagement, patient & public involvement activities

2. Providing a half day groups session for patients on ‘My Medicines’

1. What does the involve

Care Right Now CIC

1. Linking with an existing project, such as social prescribing, patient engagement, patient & public involvements activities

2. Providing a half day groups session for patients on ‘My Medicines’

3. Offering an optional Patient Led Clinical Medicines Review session for individual

patients.

1. What does the involve

Care Right Now CIC

1. Linking with an existing project, such as social prescribing, patient engagement, patient & public involvement activities

2. Providing a half day groups session for patients on ‘My Medicines’

3. Offering an optional Patient Led Clinical Medicines Review session for individual

patients.4. Action research to discover the impact

and outcomes.

1. What does the involve – patients numbers

Care Right Now CIC

1. Linking with an existing project, such as social prescribing, patient engagement, patient & public involvement activities

2. Providing a half day groups session for patients on ‘My Medicines’

3. Offering an optional Patient Led Clinical Medicines Review session for individual

patients.4. Action research to discover the impact

and outcomes.

1. What does the involve – patients numbers

Care Right Now CIC

1. Linking with an existing project, such as social prescribing, patient engagement, patient & public involvement activities

2. Providing a half day groups session for patients on ‘My Medicines’

3. Offering an optional Patient Led Clinical Medicines reviews session for individual

patients.4. Action research to discover the impact

and outcomes.

1.1 First step: ‘My Medicines’ Course for everyone.

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My Medicines 1

The aims:

• To pass on to you useful knowledge about your medicines

and treatments

• To teach you more about managing side–effects and uses of

medicines, so that you can have a two way conversation

about them with your doctor

• To show you places to find reliable information on your

medicines and treatments

• To pass on useful information about other sources of support

• To help you get the best support from doctors and health

professionals

• To pass on helpful information about coping and relaxing

• To arrange one-to-one medicines sessions

Pro-active local signposting & www.medsinfo.guru

First step: ‘My Medicines’ Course for everyone.

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My Medicines 1

The aims:

• To pass on to you useful knowledge about your medicines

and treatments

• To teach you more about managing side–effects and uses of

medicines, so that you can have a two way conversation

about them with your doctor

• To show you places to find reliable information on your

medicines and treatments

• To pass on useful information about other sources of support

• To help you get the best support from doctors and health

professionals

• To pass on helpful information about coping and relaxing

• To arrange one-to-one medicines sessions

Overall aims:• To share information on what medicines are. Including

over the counter medicines; internet bought medicines, borrowed medicines, supplements, herbal medicines, street drugs, alcohol etc.

• To provide trusted sources of information on medicines and collate information on local sources of help.

• To help people have a productive conversation about their medicines an treatments, and ‘what matters to me’ with clinicians.

1.2 Second step: Patient Led Clinical Medicines Review for those who need

more input.Individual patients reviewing their medicines in a 3/4 hour session with two health professionals (a prescriber and a pharmacist).

• A guided conversation

• Chance to discuss options in more detail

• Safe and supportive environment

AIM

To allow people the option to lead on their own care

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2. How do they work?Features

✓ Suitable for all.

✓ Part of a wider project, for example social prescribing initiatives.

✓Not specific to any condition, illness or patient group.

✓We provide people citizens / patients with an action plan.

✓Optional individual sessions carried out by a Health Professional and (always) a Pharmacist.

✓ Individual sessions are confidential.

✓We don’t take a position on any approach if it’s safe and it works.

✓We give people the notes and don’t keep a copy.Care Right Now CIC ©

Benefits:• Suitable for all, not specific to any illness or group.

• This approach educates and empowers the individual to take back responsibility and control for their health and wellbeing.

• We help citizens / patients draft their own action plan.

• Initial action research indicates potential for:

– increased engagement

– Improved use of G.P. and patient’s time

– reduction in unnecessary medicines

– Most concerning issues for the patient being identified

– previously unreported safeguarding issues being acted on

– potential reduction in bouncing referrals

– reduced unproductive contacts with GPs

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3. Related NICE Guidance

– Some key ones

• NICE Guideline on multimorbidity: clinical assessment and management

• NICE Guideline on medicines optimisation

• NICE Key Therapeutic topics

• NICE Guideline on patient experience… adult NHS services

• NICE Guideline on service user experience in adult mental health…

– Plus

• The NHS Constitution

• Department Of Health Comorbidities…system wide action

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Patient stories

Martin

‘In the support session you listened to me, and helped me work out what I needed to say. I gave the notes to my G.P. who changed my medicines and made the referrals you suggested. I now no longer walk with a stick, and feel a lot better. I thoroughly recommend these sessions’ Martin, Shepton Mallet, May 2016

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Patient stories

Ian (not real name)

I've tried everything, my GP is different every time I visit & doesn’t listen.

I’m in constant pain. I drink 8 cans of Stella a night to get to sleep.

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Patient stories

Julie (not real name)

Every time I try and go on a holiday to my daughter and grandchildren I end up in hospital. I don’t feel in control.

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More patient stories• ‘I’ve made a plan for the pain with my Dr, using the info and help given…’ Attendee Nov

2015.

• ‘The course helped me solve a (health) problem I’ve had for ages. Its’ gone now!’Attendee March 2015.

• “My counsellor says my anxiety and depression have improved. My confidence levels have gone up a lot. I’m better at talking on the phone, more assertive. I’m more proactive, for example, I dealt with my referral to the pain clinic straight away rather than leave it. I’ve made a plan for the pain with my doctor, using the information and help given by Care Right Now. I was able to be more assertive when booking my appointments and it got the results; I was put on medication for my pain and referred to the pain clinic. Other people have noticed the positive difference in me”. Attendee. March 2016

• ‘The great thing about the course is that it’s not mandatory and it’s not just given by a couple of people. The trainers were genuine people who listened and who we can trust. You didn’t have a list of things to get through with us you concentrated on what we asked and listened. Once the word gets around everyone will want this.’ Attendee April 2015.

• ‘You should listen to those guys. You will learn something’ April Attendee 2015.

• ‘Gives you the courage to question’ May Attendee 2015.

• ‘We all have different illnesses but we experience the same things and need to talk about it’ May Attendee 2015.

• ‘…really helpful…you need to think about what you’re going to say to the GP before you get there and make the time count…so I can get my point across’ May Attendee 2015.

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4. Evidence to dateFor an outline of results to date click here (NICE Shared Learning example)

1. WEMWBS

2. Patient stories and testimonials ( examples shown)

3. Thematic analysis discussion points & presenting issues

Not known (effect on):

• Cost of medicines and treatments

• GP time

• ReferralsCare Right Now CIC ©

Warwick Edinburgh Mental Wellbeing Scale

• Warwick Edinburgh Mental Wellbeing [WEMWBS] Scale scores shows mental wellbeing improved over the course of the project

• Our study showed an average increase of 6.3 points. N= 30. Time period covered Jan to March 2016.

• A difference of 3 to 8 points is considered meaningful, demonstrating that ‘mental wellbeing improved over the course of the project’.

Reference: Using WEMWBS to measure the impact of your work on mental wellbeing: A practice-based user guide (2015) NHS Scotland. WWW: http://www.healthscotland.com/documents/6074.aspx (accessed 3/4/2016)

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Thematic analysis of discussion points.Individual sessions.

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REFERRAL (PATHWAY) ADVICE

SIGNPOSTED TO TRUSTED INFORMATION

NEEDS FOR MEDS REVIEW

DOSE CHANGES

SIDE-EFFECTS

OPIOID SWITCH

INTERACTIONS

Noted personal action plans. As noted in reflective log (individual sessions) n=27/35

Thematic analysis of presenting issues

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0 2 4 6 8 10 12 14

MENTAL HEALTH ISSUESBRIEF FOLLOW UP GIVEN

ENCOURAGED TO ENGAGEANGER ISSUES

USE OF ILLICIT DRUGSSUICIDAL IDEATION

RISK / SAFEGUARDING ISSUENOT TAKING AS PRESCRIBED

SUICIDAL IDEATION WITH METHODBENEFITS ADVICE NEEDED

HOUSING ISSUEGUIDELINE MISSED

BORROWED MEDICINES

Issues brought up by patients. As noted in reflective log (individual sessions). n= 27/35

Cost savings?Our pilot work was part of a Condition Management programme commissioned by the Department of Work and Pensions.

This was measured by progress back to employment, where it was successful in its aims.

We asked people who had a medicines review to feed back on progress. In one cohort (of 15 people) two patients indicated that they no longer see the G.P. weekly as their condition is more stable. A reduction from weekly to monthly visits to the GP. Saved £2,895 per year.

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For future work: Measuring Improved quality of life

• Reduction in inappropriate referrals to other services (including 'bouncing' referrals)

• Improved adherence to medicines - e.g. stopping inappropriate or ineffective medicines

• Improved Patient Participation Group involvement

• Evidence of more appropriate visits and contacts

• Personal action plans and course feedback

• Improved mood (PHQ9)

• Return to employment or meaningful occupation

• Identification and management of previously unmet needs

• Greater uptake of lifestyle change measures and alternatives to medicines Improved mobility

• Reduced need for support from carers (paid or unpaid)

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For future work: Reducing cost of care and support services

• One prescription from a GP costs (on average) £41.35.

• A GP visits costs £45 each for a 11.7 minute consultation.

• A telephone consultation with a G.P. costs £27 for a 7.1 minutes.

• A home visit from a G.P. lasting 23.4 minutes costs £114.

• A 15 minute appointment with a nurse in a GP practice costs £13.

Reference: G.P. visit costs - Personal Social Services Research Unit [PSSRU] 2013 'Unit Costs of Health and Social Care 2013'

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5. Challenges in implementation

1. Is it cost-effective?

1. Engaging the NHS and G.P.s

2. Formal evaluation, costs & benefits

3. Governance of the model and development

Click here for the Detail AidCare Right Now CIC ©

6. Next steps• Looking for partners to develop and further

evaluate the model

• Developing implementation packs

• Writing a ‘My medicines’ workbook

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7. Where can I find out more?

• NICE Shared Learning example:https://www.nice.org.uk/sharedlearning/patient-led-clinical-medicines-reviews

• Describing the sessions (short video)

• Web site information:https://medicinegovorgmedlearn-innovation-event-nhs.blog/patient-education-support-sessions-helping-you-manage-your-own-care/

Find out more on this and shared learning across health & social care by following #MedLearn www.medicinegov.org

@MedicineGovSte info@carerightnow.co.uk

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