Beyond the dosette box:The integral role of pharmacists in Integrated Local Services

 

The Integrated Local Services (ILS) team is a coordinated network of community-based health and social care services provided by Guy's and St Thomas' NHS Foundation Trust to patients living in their own homes. Our integrated teams include occupational therapists, physiotherapists, social workers, nurses, doctors, pharmacy technicians and pharmacists. In this evolving landscape of healthcare, the role of an Integrated Care Pharmacist has become increasingly important. Our team’s vision is clear: "To promote and prolong independent living in a place of choice through the provision of compassionate and high-quality patient-centred care that improves quality of life and keeps patients well in a place they call home." This vision is more than just words: it’s the driving force behind everything we do.

The misconception that simply initiating the use of a dosette box will resolve all adherence problems overlooks the complex factors that can affect a patient's ability to follow their medication regimen. We visit the patient’s home, allowing for personalised plans to fit their daily routine. We not only get to see how they live in that environment and pick up on clues that might indicate a declining ability to cope, but we also read signals that help us to discuss what is really important to them and build our care and treatment plans around this.

 

Example: A dosette box was initiated by the GP practice due to concerns over the patient’s daily medication load, without discussing it with the patient. This led to confusion, as the patient’s heart failure medication doses were frequently titrated, causing uncertainty about medicines inside and outside the dosette. The patient, who had no cognitive issues and had managed his medications independently for years, felt his ability to manage his own care was being undermined, straining his relationship with the GP practice. A home visit and joint assessment by the medical and pharmacy teams revealed that the dosette was unnecessary. Instead, he was supported with a diuretic plan, which was communicated to the GP and community pharmacy.

For timely and effective medication management, health and social care professionals are working collaboratively and beyond traditional boundaries. In ILS, occupational therapists and physiotherapists have been upskilled to complete medicines reconciliation. By making timely contact, conducting assessments, and identifying medication errors early, therapists prevent harm and support recovery. They can then escalate to our ILS pharmacy team to help reconcile discrepancies, clarify transfer of care inconsistencies, simplify and streamline these regimens and improve medication adherence.

 

Example: A physiotherapist noticed that eplerenone was still in a dosette box, despite being stopped on discharge from hospital. The issue was promptly escalated and resolved with the GP and community pharmacy, preventing potential harm and re-admission.

As Integrated Care Pharmacists, we reach beyond the conventional boundaries of pharmacy practice to manage the complexities surrounding each patient. Our holistic approach focuses not only on medications but also on identifying and escalating concerns to the appropriate specialities.

 

Example: A patient was referred due to concerns regarding medication adherence, as the patient’s cognition had declined. Compounding the situation were mental health issues, equipment needs and problems with the care agency. Our pharmacy team, coordinated with the community mental health team, social worker and occupational therapist, simplified his medicines regimen, updated the care plan, and relieved the patient’s family of medication management burdens.

By tailoring care to individual needs and visiting patients at home, we respect their preferences and support their independence. Integrated care ensures seamless coordination between hospitals, community services, and social care, reducing care disruptions. Our work goes beyond medication management—it helps patients thrive in familiar surroundings, preserving their dignity and well-being.

The @home team provides hospital-level care in patients' homes, allowing them to receive medical treatment and support without needing to stay in the hospital. It consists of a multidisciplinary team that manages acute care, helps prevent hospital admissions, and supports patients in transitioning from hospital to home. An ordinary day consists of:

 

07:00 – Coffee in hand, I start my day by reviewing the virtual ward's caseload, identifying new patients, and preparing a list of priorities. I make sure to flag anything for discussion in our MDT (multidisciplinary team) meetings or home visits.

 

08:00 – We kick off the day with a "Big 4" team brief, always including a focus on medications management. During the handover, I review prescriptions and action any new treatment plans decided by the team.

 

09:30 – Depending on the day, I'm either in the MDT meeting with the consultant or on home visits as a trainee ACP. I’m lucky to have supportive doctors guiding me through the transition from pharmacist to ACP. MDTs are a great space for learning, where we focus on holistic patient care, beyond just following guidelines.

 

14:00 – Afternoons are reserved for follow-up work: transfer of care emails, contacting community pharmacies, handling queries, and financial reporting for FP10 expenditure. I also review incidents, manage rosters, and support the team with queries during home visits.

 

16:00 – Officially home time, but I often stay later if needed. I work 8-4 pm, arriving early most times because I thrive in the mornings, thanks to my ADHD and love for the job.

 

No two days are the same, something I love about working in the @home service. I get the perfect mix of clinical, operational, and managerial tasks, along with fantastic learning opportunities from my team.