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Case Study Two

Level 2 treatment reviews by practice support pharmacists in nursing homes in Cheltenham and Tewkesbury

Patients in nursing homes often take complex medication and have special medical needs. In the past, the quarterly visits of community pharmacists concentrated on checking storage, administration records and medicines management issues raised by the home rather than medication review. The PCT was aware that these patients needed regular medication review and explored how this service could be provided.
The PCT wanted to improve health outcomes and the well being of nursing home patients by:
  • Optimising medicines use, reducing the risks of adverse effects and minimising waste
  • Reducing the likelihood of drug interactions
  • Identifying under-used medicines
  • Withdrawing any treatments no longer appropriate
  • Ensuring appropriate drug monitoring, where relevant.
A GP or pharmacist is identified to review, once or twice a year, each nursing home resident taking 4 or more prescribed items. The patient's clinical record is used to highlight when review is due. The pharmacist or GP:
  1. Records current medication Identifying drugs and clinical indications
  2. Reviews current medication:
  • Confirms treatments still needed
  • Ensures medicines carry specific dosage instructions
  • Checks that generic names are used
  • Highlights potential drug interaction
  • Identifies adverse drug reactions
  • Identifies items not being taken
  • Reviews storage, administration, and timings
  • Checks recording of administration
  • Ensures appropriate monitoring is carried out.
If a professional other than a GP has completed the review, recommendations or a referral are made to the GP for agreement before implementing any changes. The pharmacist is responsible for ensuring that the patient's records are updated with a "medication review completed" code and that the next medication review date is recorded in the patient's computerised clinical record.
The commonest changes recommended were:
  • Discontinuation of medication no longer required
  • Further review of analgesia
  • Further review of laxatives
  • Bringing therapeutic monitoring up to date including full blood counts, U&Es, thyroid, blood pressure and lithium levels
  • Changing dosage forms switch to liquid and soluble forms for residents with swallowing difficulties
  • Review of night sedation.
Bringing more clinical and patient-focused medication review into care homes is potentially of great benefit to residents and is a way of addressing well-documented medication problems common in the care home setting. Nursing home patients are very vulnerable and it can be extremely difficult to involve them in medication review, to reach genuine agreement about treatment. It is vital that wherever possible reviewers encourage patients to express their views about their medicines so that their preferences can be taken into account in the review. In the meantime further work is needed to develop approaches to medicines concordance that can be effective in care homes.
Mandy Mathews, MMS Project Facilitator, Cheltenham and Tewkesbury PCT