Medicines-related admissions: you can identify patients to stop that happening

Medication contributes to between 5 and 20 per cent of hospital admissions and readmissions. Almost half are preventable.Admissions relating to adverse drug reactions cost the NHS up to £466m annually.

In 2004, A North West London Hospitals Trust (NWLHT) based retrospective study found that 15 per cent of general medicine cases (23/154) related to an “adverse event” (eg, a fall), of which 72 per cent were preventable. Of these events 35 per cent were related to medication.

Scullin et al investigated methods of reducing medicines related readmissions. They provided an integrated medicines management service to hospital inpatients on at least four regular medicines, who were taking a high-risk medicine, who were over 65 years and had a hospital admission in the previous six months. Interventions included medicines reconciliation, patient counselling and improved discharge communication. For every 12 patients receiving the service, one readmission to hospital was prevented. They calculated the potential saving for the service as £424 per patient. Garcia-Caballos et al reviewed the management of drug-related problems in older people after hospital discharge and found that the most effective interventions in reducing these should focus on a combination of discharge planning and home follow up.

The Harrow Integrated Medicines Management Service (HIMMS) was established in 2008 as a collaboration between Harrow Primary Care Trust and NWLHT to reduce preventable medicines-related problems and readmissions. As part of this service, we developed the PREVENT tool to help identify patients at risk.

Development of the PREVENT tool

The PREVENT case finding tool was developed using an iterative process.Published tools, including the Fleetwood model, the Combined Predictive Model (including the Castlefield model andSherbrooke questionnaire), and STOPP-START, evidence from literature, action research and expert opinion were used. The tool was refined through reflective practice, root cause analysis and patient feedback.

We identified specific factors relevant to medicines-related risks in older people from our practice, supported by the evidence. Our pharmacists use the tool when visiting patients on admission to a ward, as part of the consultation around medicines reconciliation (see Panel 1). The tool is not prescriptive; it is a guide used in conjunction with pharmacists’ clinical judgement to prioritise patients’ risks. People will refer patients with one or more unresolved issues. For example, warfarin prescribed to a housebound patient who is visually impaired will indicate increased risk only if the patient has no medicines specific support system in place.

The HIMMS team receive referrals from both health and social care professionals, but most are from pharmacists. In order to increase referral rates, we have recently adapted the tool for use by nursing staff. Patients referred get a personalised clinical pharmacy service from admission to discharge, which includes:

• Medicines reconciliation (if not previously carried out) and use of patients’ own drugs where appropriate
• Medicines review of all medicines taken (prescribed and non-prescribed)
• Counselling (for patients and carers) on all medicines prescribed and other medicines taken, including a specific adherence assessment
• Documentation of medicines changes and monitoring requirements for specific medicines within the discharge letter to GPs
• Discharge planning, which may include compliance support
• Communication with the health and social care across the secondary and primary care interface regarding pharmaceutical management requirements (including secure fax or email of the discharge information to the relevant primary care professional [eg, community pharmacist] and discussion of a follow-up medicines use review.)
• Post-discharge referral to primary care health and social care professionals, as well as carers where necessary, to ensure continuity of pharmaceutical care
• Post discharge telephone follow-up for patients or carers where required

Results so far

Over the past year PREVENT has helped to identify 147 patients considered to be at increased risk of a medicines-related readmission.

We found that there are three domains of risk associated with preventable medicines-related readmissions: medicine-specific, clinical and social risks (see Panel 2). These are similar to findings in the literature. The most frequent reasons for referral to our service were:

• Adherence issues (102 patients, 69 per cent)
• Compliance support requests (43 patients, 29 per cent)
• Patients with cognitive impairment requiring help (43 patients, 29 per cent)
• Patients taking high risk medicines without appropriate monitoring or review in place (29 patients, 20 per cent).

Some patients were referred for more than one reason.

Of the 147 high risk patients identified, 17 patients were readmitted within 30 days of discharge. The most common reasons included exacerbation of a pre-existing clinical condition (four cases), unresolved existing condition (four) and a new diagnosis (five). Readmissions were usually due to complex clinical issues, and usually involved more than one risk domain. No patients were readmitted with a preventable medicines-related problem.

The HIMMs team recognises that causes of preventable readmission are multifactorial and working within the multidisciplinary team to identify and minimise the preventable medicines-related risks is critical. We are mindful that some patients have broader needs that make medicines management risks a lower priority. For example, for patients who are housebound or who cannot safely manage daily living activities independently, discharge planning will need to take wider issues, such as shopping and cooking into account, as well as medicines issues.

Opportunities for pharmacists

We hope that other pharmacists will find the PREVENT tool useful to support patient identification and workload management, targeting pharmaceutical resource towards patients who will most benefit from interventions. For those working in hospital, we suggest that the first step is to establish a relationship with all health and social care professionals and teams involved in discharge planning for complex patients (eg, discharge co-ordinator, rehabilitation teams, occupational therapists and social workers).

Community pharmacists can use PREVENT to identify and prioritise patients who may benefit from MURs, smoking cessation, repeat dispensing, collection and delivery services, and compliance support assessments. There may be value in developing links with GP practices, district nurses, community matrons, specialist nurses, social workers and care agencies to manage risk factors identified. This will support increased referral or signposting of these patients to services they require. Further developments could include safety MURs for high risk drugs and support identification of patients eligible for the recently announced new medicine service and for targeted MURs.

In the emerging NHS landscape that includes shared responsibility across the care interfaces, GP commissioning and integrated care; pharmacists in all sectors need to be proactive in case finding and case management of patients at risk of preventable medicines-related admissions.

GPs are familiar with the nursing model (Combined Predictive Model), which supports community matrons in identifying patients at risk of readmission and this is an opportunity to extend identification to medicines-related risk. Health and social care commissioners may be interested in integrated medicines management services as a method of reducing preventable admissions and readmissions.

We are investigating ways to validate PREVENT in a range of settings. We hope that validation will provide pharmacists with a robust method of targeting their medicines management services towards patients who need support the most, working towards improved patient outcomes.