Download KSS Case Study

Medway Care Home Team
Dr Sanjay Suman – Consultant Geriatrician - Medway Foundation Trust
Prina Sahdev – Care Homes Pharmacist - Medway CCG
Background
Visiting Medical
Officer role
replaced by Care
Home Team
12 month Pilot
12 nursing homes
covered
Approx 470 beds
Integrated Team
Pharmacist
Advanced
Nurse
Practitioners
x2
End Of Life
Facilitators
Consultant
Geriatrician
Medway CCG
Medway Community
Healthcare
Medway Community
Healthcare
Medway Foundation
Trust
Reduce GP
workload, Support
Nursing Homes,
reduce Hospital
admissions, training
Advance Care Plan,
Training, Support
with Syringe Drivers,
Support residents
and their families,
supplementary
prescribers
Support with virtual
ward rounds,
Medication reviews,
Education, support
Medication Reviews,
Medication
Reconciliation,
Reduce Wastage,
Support with CQC
visits, Training
Nursing Home
Pathway
Nurse
Community teams
(Diabetes, Respiratory etc)
Pharmacist
Care Home team Admin
(Triage)
Consultant Geriatrician
(Weekly Virtual Ward
Round)
End of Life Facilitators
GP
Key Performance Indicators
15% reduction in ED
attendances (40
attendances)
15% reduction in
ambulance conveyance
(40 conveyances)
Reduction in nonelective admissions by
0.85 ratio to ED
attendances (34
admissions)
Achieve £100,000
prescribing savings in
nursing homes
100% of residents
identified as end of life
and that have an
advanced care plan in
place
Residents supported to
achieve their preferred
place of death
Increase nursing home
satisfaction
12 Month Review
KPI including pilot target
Target at 12
months
Achieved at 12
months
15% Reduction in ED attendances (40)
40
158
Achieve £100,000 Prescribing Savings
£100,000
£142,386*
100% Residents identified as end of life
with and advanced care plan in place
100%
100%
15% Reduction in ambulance conveyances
(40)
40
158
Reduction in NEL admissions (34)
34
24
Pharmacy Savings
356
• Patients reviewed
84
• Average age of patient
6
• Average number of medications
4
• Average number of recommendations made / review
£432
• Average saving per review
**
• Central Nervous System, Nutrition, Cardiovascular
£££
• Nutrition and Woundcare
Nurse Perspective
Resistance to input from NHs
Resistance to end of VMO scheme
Data collection – patchy, time constraints
Getting information from Nurses in homes
Hosted independent Forums - includes training
Relationships built successfully
Close working with GPs
Pharmacist Perspective
No resistance to input
Willingly accept advice and feedback
Audit visits to prepare for CQC audits and to support good practice
Close relationship with GP practices – rapid access to information and
advice
Difficulties with procedures – each home is individual
Medication reviews in line with Local Formulary and initiatives
Lessons Learnt
Benefits from proactive
work not evident
• Pilot extended for further 6
months
Communication within
integrated team not
recorded by nurses
• Internal Referral sheet set up
Residential units in
care homes skewed
figures
Lack of clinical
pathways
• Residential Beds to be covered by
CHT
• Workshop organised
• Pathways drafted
Future Hopes
Better links with acute frailty pathway
– From front end of hospital
Early facilitated discharge – from
wards
Better links with Out of hours teams –
follow up with end of life patients
Thank you for Listening