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SAP & Concordance

How can the SAP be used to improve concordance?
One of the key attributes of the SAP is that it uses a person-centred approach. It is vital that the service user's needs, views and wishes are kept at the centre of the assessment and care planning processes. The greatest experts in the care of an older person are the older people themselves, as they will know when they are having difficulties, the nature of those difficulties, and what might be done to resolve them. Therefore their contribution to their care and decisions about their treatment is essential.
Older people should be encouraged to participate fully in their assessment. For example, professionals could inform them of the issues that should be covered in the assessment and if possible ask them to think about their needs and issues they might wish to raise.  Overall, there are several ways in which the SAP can be used to improve concordance:
1. Increased opportunities for older people to discuss their medicines
The introduction of the SAP has the potential to increase both the number of older people who have their health and social care needs assessed and the frequency of these assessments. Therefore, if the SAP assessments appropriately address medication issues, there should be an increase in the opportunities for older people to have discussions about their medicines and for their medication-related needs to be assessed. The results of the LOPSDP project also indicated that the SAP may be a useful way to identify those patients who need a full medication review.
2. Involvement of older people and their carers in assessments and care planning
The SAP is intended to utilise a person centred approach. Users' views and preferences are placed at the heart of the assessments and care planning. The guidance to the SAP also acknowledges that patients are experts in their own needs and potential solutions and states that users should be encouraged to be involved. If this approach is taken on board by assessors then patients should become more involved in decisions about their medicines. When relatives were involved in the assessment conducted for the LOPSDP project they were found to have actively participated and contributed to the assessment process. They welcomed the involvement of the pharmacists and were keen to work together to tackle areas of concern for the older person. Furthermore, they wanted to remain involved and be informed of any progress.
3. Care plans
An important aspect of the SAP is that assessors work together with users to develop care plans to meet the user's needs identified by the assessment. A copy of the care plan should be given to the user, and to their carers and other health and social care professionals if appropriate. By distributing a clear and explicit care plan, this should ensure that users, carers and professionals are involved and informed about decisions made about the user's medicines. It is also recommended that care plans are regularly reviewed to determine if the patients' needs are being addressed. If care plans are reviewed regularly this should ensure that the efficacy of the plans are assessed and that any new medication-related needs that occur are identified early on.
The LOPSDP project found that the care packages developed included actions to improve patients' access to medicines, compliance, day-to-day management and understanding of why and how to take their medicines.
4. Ability of initial assessments (using the four trigger questions) to identify medication problems
The trigger questions cover four important categories of medication issues. The LOPSDP project showed that the questions can be used to identify a wide range of medication-related problems concerned with access to medicines, compliance, clinical issues, and day-to-day management of medicines. The phrasing of the questions should enable assessors to identify issues relating to how patients feel about their medicines, as well as any practical problems they have. The use of prompts for the trigger questions by two of the LOPSDP project sites should improve the assessors' ability to identify patients' medication-related needs.
5. Improved outcomes for patients
Recommendations made in the care plans and care packages for the LOPSDP project suggest that the SAP should have various positive outcomes for patients (and their carers). These outcomes include reduced incidence of adverse reactions, improved understanding about what their medicines are for and how they should be taken, a reduction in the under-prescribing and inappropriate prescribing of some medicines, improved access to medicines, increased compliance and improvements in users' day-to-day management of their medicines.
Potential problems that may affect the positive impact of the SAP on concordance
The aim of the SAP is to "ensure that older people receive appropriate, effective and timely responses to their health and social care needs, and that professional resources are used effectively". However, in an article in the BMJ, Grimley Evans and Tallis, two clinicians specialising in the care of the elderly, described the SAP as "unconvincing and overbureaucratic". They claim that the SAP will lead to "many boxes being ticked" but may help few people. Furthermore, they argue that it is not clear what problems the SAP will solve.
There are clearly some concerns about the SAP and the extent to which it will lead to improvements for older people or professionals. In terms of older people's medication use, it is possible that the patient centred approach of the SAP will result in increased concordance. However, there are a number of barriers which may prevent this from happening.  
1. Lack of awareness of the role of pharmacists in the SAP
Despite the fact that medication-related issues cause significant problems for many older people, there is no formal system at present to link primary or secondary care pharmacists to the SAP. Without the involvement of pharmacists, individual's medication needs may not be identified or appropriately dealt with. To combat this problem, professionals carrying out the contact and overview assessments need to be aware of pharmacists' role in conducting specialist assessments and about referral procedures.
2. Ability of initial assessors to identify older peoples' medication needs
A key aspect of the SAP is that non-medically qualified individuals will often conduct the initial (overview) assessments. The development and use of the 4 trigger medication questions may be a useful tool for these assessors to identify medication-related problems, however the LOPSDP project showed that the questions were not able to identify all of the mediation needs that the users had and one user who was identified by the initial assessment as not having any needs was later found to have numerous medication-related problems.
Despite these problems, no assessment tool is going to be 100% accurate and if assessors are given appropriate training they should be able to identify a wide range of medication needs. As recommended by the LOPSDP project, it is vital that assessors understand the principle behind each question, basic legal and ethical issues around drug supply and administration, and the role of pharmacists, other health and social care professionals and formal and informal carers in medicines management.
Another potential problem identified by the LOPSDP project was that during the initial assessments, certain types of professionals were more likely to identify particular medication issues: district nurses more often identified clinical issues and voluntary staff more often identified access or compliance problems. This issue needs to be examined further to determine if it is due to the types of individuals assessed by the different professionals or whether it is due to differences in the professionals' style and interpretation during assessments. If it is due to differences in the way they conduct assessments then the training of assessors may need to be improved to ensure that professionals do not miss particular needs.
3. Appropriateness of the 4 trigger medication questions
As discussed above, the trigger questions cover four important categories of patients' medication problems. However, if the questions are asked on their own, with no follow-up questions or open discussion about patients' beliefs and concerns, then it is likely that many medication issues will be missed. For example, the 4 questions may not identify when:
  • Medicines have been inappropriately prescribed.
  • The patient does not know that they are taking their medicines incorrectly.
  • The patient is confused about how to take their medicines.
  • The patient does not believe a medicine will help.
  • The patient is experiencing unpleasant side effects.
  • The patient is worried about the long-term effects of their medicines.
The trigger question prompts developed by two of the LOPSDP project sites may help assessors to pick up on some of these issues.
The ability of the assessments to identify patients' medication problems will also depend on the extent to which individual feels able to be honest about their beliefs, concerns and medicine-taking behaviours. Therefore, it is important that assessors develop an environment which allows users to share their views and that they deal with any issues raised in a tactful and empathetic manner.
4. Specialist assessments
The findings of the LOPSDP project indicated that the specialist assessments tended to focus on practical problems with little attention to patients' views of their medicines. In terms of the pharmacists' responses to patients' needs, there was not recognition of the potential for patients to make an informed decision to not take their medicines as prescribed, instead the focus was on providing information or practical help. The design of the specialist assessment tool used in the project also did not encourage pharmacists to work together with patients to come to an agreement about how the medicines should be taken.
5. Effectiveness of care plans developed
The SAP guidance states that explicit and appropriate care plans should be developed if unmet needs are identified. These care plans should include a description of the needs identified, the actions that are to be taken, and the intended objectives of the plan. However, the LOPSDP project found that in reality pharmacists usually wrote down very general care plans, rather than clear and specific actions. Furthermore, assessing pharmacists sometimes identified issues during the assessments that they did not address in the care plans.
Care plans need to contain detailed information to ensure that all the professionals, users and carers involved are fully informed about any decisions made. A full description of the needs and the solutions planned will also be essential when the success of the care plan is reviewed.
Another potential barrier to the successful implementation of appropriate care plans as that the community pharmacist responsible for developing and executing the plan may not be aware of all the services available or have the confidence or competencies to implement complex pharmaceutical care plans. To address this issue, SAP coordinators need to ensure that pharmacists are fully aware of the availability of, and how to make referrals to, local clinical and non-clinical services which may help address patients' needs. When patients have needs that require complex pharmaceutical care plans it may be useful for the assessing and community pharmacists to develop a care package together.