Primary and Community Care

Background: Clinical pharmacists are increasingly working as part of primary care teams in UK. Many people living with dementia live at home with the support of primary care. Given the complexity of their health problems and their use of several medications, clinical pharmacists may potentially play a crucial role in their support Aims: To explore clinical pharmacists’ experiences of working in primary care with people living with dementia and identify any specific training needs to provide effective support for this patient group.

Methods: An online survey sent via email in 2023 through professional organisations, social media, and utilising research team contacts. The survey covered topics including clinical pharmacists’ background, experience of working with people with dementia, and training needs.

Results: 57 clinical pharmacists responded to the survey; the meantime working as a clinical pharmacist was 9.6 years (standard deviation 8.6) and within a primary care setting was 6.1 years (standard deviation 6.1). Just over three-quarters of respondents (n=31, 77%) work with people living with dementia. While almost two thirds (n=35, 61%) had undertaken training for dementia care, such training often lasted a few hours (less than a day) (n=17, 49%). Most respondents (n=39, 89%) wanted further information or training; including non-pharmacological interventions to improve quality of life in dementia and how to support carers and relatives. Practice challenges reported included a lack of face-to-face consultations and getting assurance that the patient could safely take medications.

Conclusions: These findings indicate an interest in dementia care, a willingness to undertake further training but practice uncertainties that suggest a system approach might be beneficial.

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.

Introduction: Fracture liaison services (FLS) aim to prevent secondary fractures by ensuring high-quality care to all patients with fragility fractures above 50 years. The standard recommendation by FLS Database (FLS-DB) is to identify 80% of the expected fragility fractures, commencing treatment for 50% and monitoring 80% at 16 weeks and 52 weeks.

Methods: FLS team noted that only 18.4% (n=92) patients were followed at one-year of the total 875 patients identified in the year 2021 (National benchmark=22.3%). Whilst FLS team identified 42.6% (n=1649) patients in the year 2022, an 88% increase as compared to the year 2021. But there was reduction in the one-year follow-up from 18.4% to 13.8% (n=149) in 2022. Quality improvement methodology based on the model of improvement; Plan-Do-Study-Act cycles, was used. Process mapping for the existing FLS showed that follow-up was only ad-hoc and not formalised. Our objective was to improve follow-up at one-year.

Results: Process mapping supported the development of a separate clinic code for annual review of patients, led by a geriatrics specialty trainee and supported by the FLS Clinical Lead. The patient lists were drawn from the FLS-DB and new patients booked for one-year follow-up clinic. FLS identified more fragility fracture patients (n=2181, 61.4%) in 2023, a further increase of 32.2% as compared to previous year. Clinical leadership and dedicated one-year follow-up clinic supported improved performance (21.4%, n=310) in the year 2023, which is comparable to the national benchmark (22.2%).

Conclusion: Several challenges were identified including lack of accurate telephone numbers for many patients; patients are transferred to primary care at one-year but there but the is osteoporosis knowledge gap in the community and need for dedicated time for follow-up clinic. This quality initiative has streamlined our follow-up clinics but need dedicated time to meet the service demand and increased capacity.

Introduction

University Hospitals Dorset (UHD) wants to provide hospital level care to patients with frailty, in their own home. Our frailty virtual ward (VW) team consists of a consultant geriatrician, lead nurse, pharmacist, advanced nurse practitioner, nurses and therapists. We have a capacity of 20 patients across Bournemouth, Christchurch and Poole localities. Our patients receive care at home for acute medical conditions supported by remote monitoring, blood testing, face to face assessments and daily Geriatrician input. We are collaboratively working with our community partners seeking to provide complete CGA in the patient’s home.

Methods

Establishing the service was non-linear and required multiple improvement cycles. Our VW fits alongside our frailty SDEC, day hospital and interim care team. We developed a SOP, a patient flow pathway and processes for medication prescribing and delivery supported by the Royal Voluntary Service. We screened our frailty wards for suitable patients and in May 2023 we tested by taking our first patient home. Subsequently our processes have developed around the patient’s needs. Through multiple PDSA cycles we tested various screening techniques, 7 day Geriatrician input, nurse recruitment, remote monitoring and used patient feedback to guide further service development and improvement.

Results

We are an established frailty virtual ward with 20 beds.

Conclusion

The UHD Frailty VW has developed out of a need for an early supported discharge and admission avoidance for our older patients. Through multiple PDSA cycles, we have established a virtual model that we feel is providing safe, hospital level care for patients with acute medical presentations. We hope to expand through recruitment and funding with an aim to deliver excellent quality care to patients with frailty in their in their own home. Our ambition includes closely working with South West Ambulance Service for further admission avoidance and developing a home IV pathway.

Introduction The Chandlers Ford, Eastleigh and Southern Parishes Frailty Support Team (FST) identified pockets of high referral rates within independent living facilities. It was hypothesised that this may be because independent living facilities do not have a contractual arrangement for proactive intervention, unlike care homes and nursing homes. This leaves individuals and carers unsure how, when, and where to seek support. In turn, this potentially has a high healthcare burden through unplanned access to GP’s, 999, 111 or admissions to hospital.

Methods: An independent living facility was identified, and participants were invited to have a proactive, holistic review. Medical notes were reviewed for 12 calendar months prior the project and all unplanned contacts recorded. Each participant then received a face-to-face review which identified, addressed and rectified any findings/ concerns. A follow-up review of medical notes and a telephone call to participants was completed 3 months later; 3 months after telephone review medical notes were reviewed to identify incidents of unplanned care.  

Results: This project has decreased unplanned medical contacts by an average of 52% in all participants which equates to an average 6-month gross saving of £431 per person and a 6-month net saving of £383 *Net savings allowed for 3 hours of Agenda for Change 23/24 mid band 7 pay. Trend shows face to face contact has the best impact at reducing unplanned care incidents, however this does not affect the emergency needs secondary to trauma.

Conclusions: The project suggests that in independent living facilities switching from a reactive to a proactive model may allow for better holistic care, in turn reducing the burden on the local health services. It is acknowledged that this is a small sample and therefore may not be representative or generalisable and a larger study is recommended.

Improving Advance Care Planning Within Residential Homes

Introduction:

As care home residents are living with advancing frailty and multi-morbidity, it is important to initiate advance care planning as part of the comprehensive geriatric assessment and create universal care plans (UCPs). There is evidence that it can reduce inappropriate escalations of care, reduce hospital admissions, increase the proportion of residents dying in their preferred place and improve both resident and relative satisfaction.

Method:

Retrospective audit in June 2024 of residents within the five residential homes covered by the newly formed enhanced health in care home (EHCH) team who had an initial comprehensive geriatric assessment (CGA) between March 2022-May 2024 to review if they had a universal care plan in place (UCP).

Further sub-analysis to review whether they had an existing UCP prior to EHCH review or this was created/edited by the EHCH team. Both the CGA and UCP would have either been completed by the EHCH matron or consultant geriatrician.

Results:

There was an average increase from 26% to 89% in the number of residents with a UCP following an EHCH CGA. We have created/edited a total of 117 UCPs across the care homes in addition to those already in place across the 177 CGAs completed over this time period.

Conclusions:

Advance care planning is a vital part of a comprehensive geriatric assessment and it is often not completed for many reasons including its time-consuming nature, lack of awareness and apprehension in having these discussions both amongst residents, relatives and staff and a lack of training and education.

As an EHCH team, we have managed to improve the number of residents with UCPs to 89%. We hope this will mean a greater proportion of residents receive appropriate personalised care according to their wishes in their chosen place as well as dying in their place of preference.

Introduction: Approximately a third of community dwelling adults over the age of 65 fall each year, with around half experiencing more than one fall per year. Currently within North Tyneside older adults who have had a fall, or are at risk of falling, may be invited to attend a specialist falls clinic; if appropriate they may be referred to Age UK North Tyneside’s Strength and Balance Class. Improving strength and balance in those at risk is an established intervention, yet adherence to programmes, and the subsequent adoption of exercise post-intervention varies. This work aims to explore why participants attended (or did not attend) the classes, whether they felt benefit from the classes and if they had adopted any new behaviours into their day to day routines. Method: 18 users of the Age UK Strength and Balance users were recruited from the quantitative arm of our mixed methods project, having been attenders of both the North Tyneside Community Falls Prevention Service (NTCFPS) and Age UK classes. Participants were interviewed in the NTCFPS over a 9 month period in 2023. Interviews were audio-recorded and transcribed verbatim, with an inductive thematic analysis approach selected for analysis. Results: Findings revealed a broadly positive experience of the classes, with participants particularly engaging with the shared background that the classes’ social support offered. Participants that were previously active were more likely to engage with further strength and balance training or resources, often wishing to continue with classes provided by Age UK. Conclusions: Users of the classes enjoyed the programme, regardless of if they felt they received benefit from them. Addressing common barriers requires better communication of logistical aids available to them. Further work is required to understand preferences of facilitators and barriers of completing further classes or training, either independently or in a group environment.

Introduction:

Frailty Hotline Service (FHS) was set up initially in January 2021 to provide 24/7 advice and guidance to care home medical staff within the Mid & South Essex Health and Care Partnership footprint as a part of covid response. This was expanded to support GPs, Urgent Care Response Team (UCRT), community hospitals, hospices etc and later established as Community Frailty Hotline Service (FHS) with an aim for hospital avoidance and provide support to frailer older patients in their own places. Later, a Frailty Virtual Ward (FVW) was established to complement FHS within the MSE HCP.

Methods:

FHS was led by 5 secondary care consultant geriatricians with direct access to telephone, 7 days service operating from 9 am till 10 pm weekdays and 9am till 10pm weekends in 1:5 rota. Unified online portal ‘Netcalls’ was used to directly call consultants. Documentation completed on dedicated Frailty Consultant Hotline Tab on SystmOne to be visible to all care providers. Data-collection automated via Netcall and SystmOne from March 2023 till January 2024.

Results:

Average number of call was 487/ month, 2098 advices given over 11 months. Referral mostly done by UCRT 1511 (72%) followed by GP 193 (9.19%). Hospital admission avoided in 7 days and 30 days where the advice given in 82.9% and 73.6% cases, respectively. Total bed days saved was 13920 Cost saving was over six million. Frailty score completed in 2982 cases. FVW referral done in 853 cases (40.6%). Feedback from FVW and UCRT, 95% found FHS was useful.

Conclusion:

Our innovative model of FHS with direct access to geriatrician showed a safe and efficient model to support frailer older patients in the community with appropriate signposting to FVW and other community services as an alternative to acute hospital emergency admission and treat the right patient in the right place.

• Collaboration between a nursing home and an ambulatory geriatric-psychiatric team to patients with Behavioral and Psychological Symptoms of Dementia (BPSD)

Introduction

Healthcare professionals in nursing homes collaborate with specialized healthcare services to manage and support patients with BPSD. Geriatric- psychiatric ambulatory teams from the specialist health service provide professional assistance to healthcare professionals and family members for patients with geriatric psychiatric disorders and BPSD. This outreach- service is not very developed and could be further expanded. The study aimed to elucidate the collaboration between municipal health services and ambulatory geriatric-psychiatric teams within the specialist healthcare service.

Method

In this qualitative study we conducted individual interviews with six healthcare professionals representing four different nursing homes. The analysis is inspired by systematic text condensation. The research project has been submitted to the Norwegian Centre for Research Data.

Results

The informants expressed the importance of enhanced interaction with the specialist healthcare service in general and to patients with BPSD in spesific. When the informants receiving support from the team, the interaction is deemed more valuable and constructive. They find a shared meeting point with opportunity for sharing knowledge and engaging in dialogue.

Conclusion

The study indicates that health professionals see the importance of improved collaboration with specialized health services for patients with BPDS. When ambulatory teams engage actively, they experience collaboration characterized by closeness and shared understanding. The ambulatory-geriatric psychiatric team may become more well-known and the method of requesting professional help from the team can be made more transparent and clearer. It is also important that healthcare personnel proactively request professional assistance for patients with BPSD. With the increasing prevalence of patients with dementia, there is a need for further research to address the challenges in this area. Ambulatory geriatric-psychiatry teams are a service that should be explored further.

Purpose

To investigate physiotherapists’ perspectives of effective community provision following hip fracture.

Methods

Qualitative semi-structured interviews were conducted with 17 community physiotherapists across England. Thematic analysis drawing on the Theoretical Domains Framework identified barriers and facilitators to implementation of effective provision. Interviews were complemented by process mapping community provision in one London borough, to identify points of care where suggested interventions are in place and/or could be implemented.

Results

Four themes were identified: ineffective coordination of care systems, ineffective patient stratification, insufficient staff recruitment and retention approaches and inhibitory fear avoidance behaviours. To enhance care coordination, participants suggested improving access to social services and occupational therapists, maximising multidisciplinary communication through online notation, extended physiotherapy roles, orthopaedic-specific roles and seven-day working. Participants advised the importance of stratifying patients on receipt of referrals, at assessment and into appropriately matched interventions. To mitigate insufficient staff recruitment and retention, participants proposed return-to-practice streams, apprenticeship schemes, university engagement, combined acute-community rotations and improving job description advertisements. To reduce effects of fear avoidance behaviour on rehabilitation, participants proposed the use of patient-specific goals, patient and carer education, staff education in psychological strategies or community psychologist access. Process mapping of one London borough identified points of care where suggested interventions to overcome barriers were in place and/or could be implemented.

Conclusion

Physiotherapists propose that effective provision of community physiotherapy following hip fracture could be improved by refining care coordination, utilising stratification techniques, employing enhanced recruitment and retainment strategies and addressing fear avoidance behaviours.