North Bristol Care Home Interface Project (N-CHIP) is an interdisciplinary team of frailty experts from North Bristol NHS Trust, funded as a pilot through Ageing Well, and working with GP practices and care homes within surrounding Locality Partnerships.
The project launched in January 2022 with the aim of providing focused comprehensive geriatric assessments to care home residents, including a structured medication review (SMR) and advance care planning (ACP) using the ReSPECT template.
Interdisciplinary, not multidisciplinary
The team comprises a consultant geriatrician, specialist frailty pharmacist, GPs with specialist interest in frailty, a clinical fellow, physician associate and paramedic frailty practitioner. Each member of the team undertakes the same day to day role in reviewing care home residents, completing all aspects of the review but drawing on expertise from other team members where needed. As such, the team works on a interdisciplinary rather than multidisciplinary model. Working in this way has allowed the upskilling of all members of the team, whilst still recognising the strengths and expertise of the different professions.
How do ACP and SMR fit together?
The objective of ACP is to explore and record a person’s priorities for their health care, now and in the future, and in the context of their co-morbidities, functional state and likely prognosis. These priorities should also form the basis of a person-centred structured medication review, and discussion of one neatly leads into discussion of the other. Understanding a person’s priorities and their likely prognosis can help frame medication risk-benefit discussions and promote shared decision making. A good medication review can also influence prognosis: medication review within six to twelve months of admission to an aged care facility has been associated with a four percent reduction in mortality risk (and six percent for those on nine or more medicines).
What are the benefits of the project?
Interim data from the first six months of the pilot showed an average annual cost saving per resident of almost £170, with overall net annual savings of over £131,000 for the 798 residents seen during this time-frame.
Medicines stopped during reviews included three classes that have been shown to cause 40 percent of preventable hospital admissions due to adverse drug reactions: diuretics (stopped for 42 residents), antiplatelets (stopped for 34 residents) and anticoagulants (stopped for 26 residents). Antidepressants were one of the most common drug classes reviewed by the team, being weaned and/or stopped in over 100 residents.
New or updated ReSPECT forms were completed for 416 residents, with over 50 percent of residents preferring to avoid admission to hospital in the event of acute illness. Early data from care homes known to have high admission rates showed a reduction in ambulance call-outs and conveyance to hospital following input by the team.
What is it like to work as a pharmacist within the team?
As a frailty pharmacist I have a passion for tackling polypharmacy and promoting deprescribing. This project has allowed me to apply expert knowledge, using independent prescribing to action outcomes from reviews whilst also learning new skills and developing as a clinical practitioner.
Through completion of a competency framework developed within the team, I have been able to demonstrate the necessary skills in completing ACP discussions and documentation. It is a privilege to be able to support people and their families to consider their options and wishes in their final years.
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Competing interest statement:
The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.