Ana Armstrong
In 2019, I joined the community medical team and frail older people service at Surrey Downs Clinical Commissioning Group (CCG) as lead specialist pharmacist. The service was developed by a fellow lead pharmacist, Emma Dubrau.
Having previously worked as a pharmacist in an acute hospital setting, I often wondered how my older patients were getting on with their medication at home and I found myself worrying about what the answer might be. I find my current role at Surrey Downs CCG satisfying because the service addresses all aspects of patient medication use in the community.
Pharmacists work with the core community medical team, which consists of community support matrons, care coordinators and a GP at the Dorking and East Elmbridge hubs. The team also has access to physiotherapists and occupational therapists. Our patients are mostly older people; they are sometimes frail and often require extra support — including with their medicines. As a result, these patients may be frequent attendees to hospital emergency departments and we aim to support them in their homes as much as possible.
There is limited deprescribing guidance for complex patients who have multiple comorbidities, which can be challenging
For pharmacists, the most common challenges are: polypharmacy; poor adherence with medication regimes; increasing frailty; deteriorating kidney function; falls; and patients approaching the end of their lives. There is also limited deprescribing guidance for complex patients who have multiple comorbidities, which can be challenging.
09:00 — start
Today, we have a multidisciplinary team meeting where we discuss the five to ten patients we are most concerned about from the team’s entire caseload. I make sure I have access to each patient’s medicines list, any blood test results and notes from recent medical consultations, as well as a copy of recent clinic or discharge letters.
We discuss a patient who had declined a home visit the previous week. He is short of breath and the physiotherapist is particularly worried about him. I explain that he is under regular respiratory review for his COPD, which is generally well controlled. Therefore, his symptoms are likely to be resulting from non-adherence to furosemide, a diuretic that he has been prescribed for his recently diagnosed heart failure. We refer him for an urgent visit from the community matron and suggest that his GP reviews him too, if necessary.
After the meeting, I reflect on whether I could have done more to convince the patient to take his furosemide. I did manage to talk with him over the phone, but face-to-face discussions always work better.
11:00
I head out to visit an older patient experiencing polypharmacy who we think may be non-adherent to her medicines. We also suspect that she may have undiagnosed dementia. Before visiting any patient, I ensure that I know the indication for each of their medicines and the results of any recent blood tests.
When I arrive, it is apparent that she is overwhelmed by her medication. She has tablets dating back several years, some of which have expired. She has no reliable way of knowing what she takes throughout the day and, judging by the quantity of tablets, I suspect she is not taking them.
I check her blood pressure and note that it is high — she needs to start taking antihypertensive medication again. I simplify her medication regime as much as possible using my clinical judgement and deprescribing tools, STOPP/START (a screening tool to alert prescribers to inappropriate treatment) and the Scottish Intercollegiate Guidelines Network’s polypharmacy guidelines. Once her GP approves my recommendations, I will contact her community pharmacy and ask them to dispense the medication in a blister pack.
Back in the office, I write up my notes. The community medical team is in the process of implementing a once-daily package of care to help the patient in the mornings and will help supervise her medication, so I communicate my concerns to the team which will be visiting her in a few days’.
13:30
I check my caseload after lunch and notice some new patient referrals. Unfortunately, I lack the capacity to carry out home visits for each new patient, so I prioritise them into different levels: face-to-face home visits; medication list reviews; or discharge without any contact, for those who do not require pharmacist input.
One referral is for an older patient with deteriorating kidney function, but who is only taking a few medicines. After checking their indication, I work out his kidney function, ask the GP to reduce his dose of rivaroxaban (as per the summary of product characteristics) and I call the patient to inform him of this change. As I have not visited him at home, I record this as a medication list review.
A lot of patients struggle with medication changes after discharge, so I like to visit them when they’re back home
My next referral is for a patient who has been experiencing falls. Her blood pressure and heart rate are well controlled and there are no reports of a postural drop. I work out her anticholinergic burden based on her prescribed medicines; she has a score of 1, which is low. The higher a patient’s burden, the higher the risk of falls. I check a few other resources and discharge her without an intervention. I am confident that the medicines this patient is taking are not contributing to her falls and I feed this back to the matron.
15:30
One of our patients has been admitted to a local hospital. I contact the pharmacy department to provide them with a correct medicines history and ask to be kept informed of any changes to their medication on discharge. A lot of patients struggle with medication changes after discharge, so I like to visit them when they’re back home. It is also good to build bridges between primary and secondary care as, at the end of the day, we all look after the same patients.
16:00
A matron refers an older male patient to me who she visited today. He has Parkinson’s disease and is approaching the end of his life. His daughter looks after all his medication, but he has found it increasingly difficult to swallow tablets. The matron asks about liquid formulations and requests a medication review in light of his poor long-term prognosis. After explaining the potential liquid formulations that could be suitable for this patient, I schedule him in for a review.
17:00 — finish
It has been an interesting day with a lot of challenging patients, but I feel that I have been able to help improve their care even if only in small ways. I find going to visit patients in their own homes the most rewarding part of my job and the patients always appreciate my input.
Information for pharmacists interested in a similar role
- At Surrey Downs Clinical Commissioning Group, the minimum level of a role in this team is Agenda for Change band 8A — we expect pharmacists to have completed their clinical diploma and ideally be independent prescribers;
- Have a good working knowledge of frailty and polypharmacy, as well as experience in deprescribing. The study days run by the UK Clinical Pharmacy Association Care of the Elderly Group and the Older Peoples’ Network, a group developed by pharmacy practitioners working with older people, are all good places to start;
- Do not be afraid of temporary positions. If you can show you are improving patient care there is a good chance that longer term positions will become available;
- Enjoy working with older patients who are often housebound, not very mobile and lack contact with other people — they will often want to chat while you are visiting;
- Be open to taking on new roles, such as checking blood pressure, weight and even taking blood tests.
