CQ - Efficiency and Value for Money

Introduction 

Older people living with frailty are often prescribed many medications exposing them to potential medicine-related harm. Pharmacists are a new addition to the East Kent Community Frailty Team, which otherwise consists of doctors and advanced clinical practitioners at various levels of training. Pharmacists are ideally placed to develop medication review processes and support fellow clinicians with deprescribing efforts in frailty. This audit set out to determine current levels of medication review and associated cost-savings through deprescribing. 

Method 

All patients admitted to the frailty team caseloads in the month of May 2023 had their notes manually reviewed for evidence of medication reconciliation, review, and deprescribing. Medicines were assigned a cost price based on the NHSBSA Drug Tariff (May 2023). 

Results 

192 patients were seen in total, 170 of whom were acutely unwell. 62% of patients had their medication documented, taking an average of 8.2 medicines. The majority of omissions were patients with a zero length-of-stay, which include advice calls. 29% of patients had at least one medication stopped, representing an average 0.7 medicines stopped per patient seen. The monthly cost of medications stopped was £690. There were greater levels of deprescribing in the caseloads with MDT board rounds. 

Conclusion 

Rates of deprescribing are low compared to published studies (Ibrahim et al, BMC Geriatr 21, 258 (2021)), although still represent a rolling saving of approximately £8,000 per month on cost of medicines alone, assuming a twelve-month average life expectancy. Lack of standardisation of clinical notes and documentation made data collection difficult and has the potential to lead to transfer-of-care errors. Further work needs to be undertaken to optimise the medication review process and address inappropriate polypharmacy and will be the focus of efforts over the coming year. 

Introduction: Frailty presents significant challenges to healthcare systems, particularly in Thurrock, Essex, where 14% of residents are aged 65 or older. This demographic shift, combined with socioeconomic factors, highlights the need for patient-centred, clinically effective, and tailored healthcare services that prioritise patient safety. 

Aim: To improve frailty management for elderly patients in Thurrock by integrating pharmacist support within a nurse-led service. The initiative focuses on improving medication management, alleviating workload pressures, and providing holistic care to enhance patient outcomes and reduce hospital admissions. 

Method: A 12-week pilot involved patients aged 65+ undergoing joint reviews with a frailty nurse and pharmacist. Participants had a Rockwood Frailty Score of 5-7 and at least one long-term condition. The reviews encompassed an evaluation of physical observations, medication regimen, functional and fall risk assessment, nutritional status, fracture risk, and analysis of pertinent blood test results. The management phase focused on reviewing long-term chronic conditions, deprescribing, medication dose adjustments, and addressing health metrics such as postural hypotension, bradycardia, bone protection, and fall risk. Regular follow-ups ensured coordinated care between the nurse and pharmacist, focusing on patient-centred outcomes and patient safety. 

Results: A total of 37 patients (mean age: 84) participated from April 4^th to June 28^th, 2024. Comprehensive assessments led to 155 interventions (averaging 4.07 per patient). Medication management improved significantly, with 88 drugs deprescribed, including 55 Falls Risk Increasing Drugs (FRIDs), resulting in a 14.39% reduction in FRIDs and a 23.03% reduction in polypharmacy. These interventions led to £6,252.18 in annual drug savings and a 974.09 kg reduction in CO₂ emissions. Key outcomes included 57 health and social interventions and 38 new medications prescribed. Financial analysis suggested savings of £63,450 from preventable hospital admissions, with a return on investment (ROI) of 1655.4%.

Conclusion: The pilot demonstrated the clinical effectiveness of pharmacist-nurse collaboration in improving medication management, chronic condition control, reducing fall risk, and preventing hospital admissions. It underscores the value of skill mixing between professions for enhanced patient-centred care, safety, and clinical outcomes.

Introduction: 

Polypharmacy contributes to frailty, financially strains healthcare resources and causes unplanned hospital admissions. We audited how our Frailty Same Day Emergency Care (SDEC) addressed polypharmacy and the yearly financial impact of deprescribing on the NHS. 

Method: 

We analysed two months of patients seen and recorded medication changes in Excel. The BNF was used to provide the minimum NHS indicative price for a medication. Cost was calculated based on a year of prescribing for medications started, stopped or altered. For PRN medications, single pack usage was assumed. The average monthly saving was then multiplied by 12 to estimate the yearly value. 

Results: 

226 patients were reviewed, with 181 having recorded medication changes. From this sample, the estimated yearly saving through deprescribing is around £31,780. Furosemide, amlodipine and atorvastatin were the most frequently stopped. Anticipatory medication and laxatives were most frequently started. Stopping ticagrelor resulted in the greatest savings (£711.44), whilst the most expensive medication started was mesalazine granules (£897.16). 

Limitations: 

The estimated yearly saving is based on assumption and so can be subjected to anomalous results/prescribing. Alterations are assumed to be permanent and continue throughout the year. PRN usage was generalised and not reflective of true usage over a year. The estimated saving does not account for negative financial complications because of deprescribing (e.g. stopping stomach protection and then representing with an Upper GI Bleed). Whilst deprescribing can result in direct financial benefit to the NHS, true benefit has not been measured (reducing future admissions due to polypharmacy). 

Conclusion: 

The NHS can incur significant financial savings from a frailty day unit. The direct cost reduction of deprescribing is only one of the benefits of addressing polypharmacy. The true value is in improving quality of life, reducing the impact of frailty syndromes and avoiding hospital admissions in older people.

Introduction Frailty is associated with delayed clinical assessment in ED, increased length of stay (LOS) and inpatient mortality. Frail older adults have complex medical and psychosocial problems, difficult to address in ED. In line with the NHS Long Term Plan, our fSDEC pilot aimed: to deliver early comprehensive geriatric assessments (CGA); manage acute presentations to avoid unnecessary admissions; reduce ED waits and reduce the LOS for those admitted. Methods The fSDEC pilot had an ACP, a trainee ACP and two resident doctors (SHO and registrar) with support from a consultant and access to a therapist, a pharmacist and urgent community response teams. Patients were triaged by fSDEC for suitability on weekdays 8am – 6pm. Ambulant patients were seen in pre-existing shared SDEC space; non-ambulant patients were managed in ED. All patients had a CGA within thirty minutes of arrival. Results In twelve months, 729 patients were seen and 81% discharged same-day. Table 1: Categories of presentation: Most common was fall 39%. Table 2: Number of patients seen each month and number of days fSDEC not run: average number of patients seen 3.5/day Without fSDEC it was estimated 80% of these patients would have been admitted. For example, patients who present with falls have an average LOS of 13 days. fSDEC saves 234 bed-days/month for falls, which amounts to £70,000/month. For total presentations this can be extrapolated to 620 bed days, saving £186,000/month. Conclusion With fSDEC there was higher likelihood of same-day discharge; improving flow, patient experience and offering financial savings. This was aided by engagement from stakeholders, access to community In-Reach CNS and flexibility of staff. In future, we aim to have a frailty friendly space and more consistent staffing. There was positive feedback from patients and the Trust (the team were finalists for 'All Star Team of the Year').

Background

Dementia is a prevalent condition in an ageing population. Persons with dementia and their caregivers are often uncertain about what to expect after an initial diagnosis. Previous studies conducted on the experiences of informal caregivers show a clear demand to address these: providing adequate information, psychosocial support and access to services.

Introduction

The diagnosis of dementia is usually made by specialists in the tertiary hospital. However, resources in acute tertiary hospitals are expensive and valuable. To better allocate resources and improve the manpower situation, we have collaborated with our community partner to provide post diagnosis support (PDS) to patients newly diagnosed with dementia.

Methods

A PDS team consisting of an allied health professional and a caregiver peer is established by our community partner. They conduct home visits to provide psychoeducation to help persons with dementia and their caregivers understand more about dementia, develop personalised care plans, and coordinate support services to provide psychoemotional support.

Close communication is maintained between the PDS team and the acute hospital referral team. Multidisciplinary team meetings involving the geriatricians, nurses, case managers and community partners are also held quarterly to provide regular updates about the progress of the patients and facilitate learning.

Results

A total of 95 persons who were newly diagnosed with dementia in the previous 1.5 years were referred. 53 patients were eventually enrolled under the PDS programme, and received psychoeducation and personalised care plans. 72% were given caregiver support and 66% were linked up to community services. The average duration between date of referral to date of first home visit is 13 days.

Conclusions

In an ageing population where there is high healthcare utilisation, it is efficient to utilise existing services instead of duplicating them. By collaborating with community partners, we are empowering them to play a better role in supporting persons with dementia.

Introduction: Our aim is to improve clinical efficiency by reducing avoidable discharge delays, increased number of discharges and availability of specialist Frailty beds. We intend to undertake 8 PDSA cycles with a new idea.

Background: 23 bedded Acute Frailty Short Stay Unit (AFU). Patient group defined as those admitted to the unit from April ’24 to current. Our initial spot-audit analysed 18 patients; the mean total avoidable delay was 31.52 hours (range 4.73- 123.3 hours). Initial analysis demonstrated that delays became longer throughout the course of the day. Methods: We evaluated staff opinions on the discharge process with a survey. Outcome measure identified as number of weekly discharges and appropriate patient flow to the AFU. Balancing measure identified as number of readmissions within 48 hours. PDSA cycle 1 allocated a doctor to write discharge letters during MDT. PDSA cycle 2 allocated a suitcase symbol to a potential discharge in the next 24 hours. We then adapted the suitcase with colours to differentiate between ready and awaiting investigations/ aim home in 24 hours. The next involved allocating a discharge doctor to review patients with an amber suitcase from the previous day first.

Results: Initial staff feedback has been positive. Data demonstrated an increase from the baseline (from below 20 to an average of 25 discharges a week). This then dipped throughout May, during which time there was an unusual level of escalation, staff absences and annual leave. The data has begun to recover to a high of 27 discharges in the week of the start of June.

Conclusions Utilising the MDT has been vital in the sustainability of the project. On-going staff surveys and regular meetings will help to ensure sustainability. Ongoing focus and further cycles are on encouraging junior members of the team to be involved with the intervention.

Introduction

We proactively reviewed nursing home residents using a multidisciplinary team (MDT) approach within a Primary Care Network (PCN). We aimed to enhance care coordination, reduce inappropriate medication use and ensure all residents had current advanced care plans in place.

Method

An MDT comprising a geriatrician, prescribing pharmacist, general practitioner, and nurse reviewed residents proactively. This involved reviewing the residents' current health and care needs, falls risk, medication regimens and advance care plans. We then performed medication reviews, reviewed advanced care plans, and identified the need for further interventions. When we repeated the process, we used a proforma that could be pre-populated prior to the meeting by the pharmacist and geriatrician to improve efficiency of the discussion.

Results

The initiative was piloted in two residential nursing homes with a total of 65 residents reviewed, of which 86% (n=56) received interventions. There was a 47% (n=29) increase in completed advanced care plans. 62% (n=40) of residents had medicines optimised, with polypharmacy being reduced in 46% (n=30) by an average of 2 medications per resident. 8% (n=5) were referred to additional services and 8% (n=5) required further investigations.

Conclusion(s)

This proactive MDT model effectively addressed the needs of residents whilst demonstrating immediate positive outcomes. Key facilitators to good practice were teamwork, clarifying the objectives of the MDT, prior reviews of patient records, and ensuring staff who knew the residents well were present. We will use this approach with other nursing homes within the PCN and share our results with colleagues. This has the potential to reduce costs of medications and hospital admissions, as well as improve quality.

Following COVID and an aging population waiting lists in Swansea Bay for elective procedures along with the rest of the UK had reached an all time high. Many patients have become frailer over time and may no longer be suitable or keen for surgery. There was not an efficient mechanism in place for screening these patients and many were being cancelled on the day or having pre-op assessments close to the time of surgery and found to be unsuitable. As part screening our elective surgical waiting lists for frailty we used a number of mechanisms including a electronically screening questionnaire. This was sent to 78 patients highlighted through power BI as meeting frailty criteria and on surgical waiting lists. The questionnaire consisted of a ‘self CFS’ reworded alongside K Rockwood and questions from the CRANE questionnaire. The patients were sent a link with a brief outline of the purpose of the questionnaire and the potential need to be called to clinic if they had any frailty needs. There was a contact number for a admin assistant if there were queries. If they couldn’t access the technology they could also contact them complete via telephone. Over 50% of patients completed the questionnaire online. Interestingly the majority of patients completing the questionnaire had a clinical frailty score over 4 (calculated via clinicians). A clinician also calculated a frailty score for the patients completing the questionnaire which showed good concordance between patients ‘self score’ and a clinicians score. This work showed that our frailer population are able to use technology to good effect and pending more research there may be a role for patients to ‘self score’ themselves in a clinical frailty score. This is invaluable in cutting down resources needed for screening for frailty in many areas

Introduction: Inadequate patient selection for transfer to community hospitals disrupts care continuity and compromises patient safety and outcomes. The SBAR communication tool presents a promising solution to address this challenge. This study investigated the impact of SBAR on quality of care and patient outcomes.

Methods: Retrospective study involving patients admitted to Samuel Johnson and Sir Robert Peel Community Hospitals from October to November 2023. Data regarding the completion of the SBAR forms, accepted and rejected patients and reasons for rejection, and repatriation numbers were gathered. Comparisons were made against our previous study in 2021.

Results: 403 patient referrals have been made. 266 were accepted, 137 (34%) were rejected. Of the rejected patients 52 were due to medical reasons, while 85 were non-medical reasons. Compared to data from 2021, 137 out of 403 referrals (34%) were rejected in 2023, 3 out of 155 (2%) were rejected in 2021. There were 76 repatriations in 2023 (average of 26/month), whereas there were 139 repatriations in 2021 (average of 46.33/month). The decrease from 139 repatriations in 2021 to 78 in 2023 indicates a notable improvement in patient outcomes and healthcare management strategies. The decrease in repatriations not only reflects potential cost savings but also underscores the efficacy of interventions aimed at minimizing healthcare disruptions and optimizing patient well-being.

Conclusion: By facilitating a standardized and comprehensive handover between acute and community providers, SBAR ensures patients receive the appropriate level of care at the community setting. Moreover, SBAR empowers healthcare staff to confidently make decisions regarding transfer acceptance or rejection, prioritizing patient well-being throughout the process. The findings revealed significant improvements in both the quality of care and patient safety following the adoption of SBAR. Additionally, SBAR utilization demonstrated a notable reduction in the financial burden on the NHS.

Hip fractures are a major public health issue due to ageing populations and Ireland has one of the highest hip fracture rates in Europe1. The cost of acute hip fracture care was 48.5 million euros in 20221. The Irish Hip Fracture Database in 2022 revealed that 84% of people presenting to acute hospitals with hip fracture were admitted from home, however only 29% were discharged directly home1. NICE guidelines recommend early supported discharge for patients who are medically stable and mentally fit to participate with rehabilitation and who can transfer and mobilise short distance but have not yet achieved their full potential2. The National Integrated Care Programme for Older Persons (NICPOP) improves the life of older people by providing access to integrated care and support that is planned around their needs and choices, supporting them to live well in their own homes3. This poster outlines the rehabilitation pathway established by the SJH ICPOP team to provide early supported discharge for hip fracture patients.