Information is care: the need for data to assess the quality of care in UK nursing and residential homes

Prescribing is the most common medical intervention experienced by elderly residents in nursing and residential care homes. However, research would suggest that these residents may be subject to poor prescribing, with excessive use of some drugs and underprescribing of potentially beneficial drugs. At a more fundamental level, there is also evidence that poor medication record-keeping for nursing home residents is prevalent in nursing homes, general practice surgeries and community pharmacies. This may increase the risk of an adverse drug event. Furthermore, there is a lack of data on prescribing in UK nursing homes, which militates against assessing the quality of drug use. Consideration needs to be given to the structures and processes currently in place in order to promote better prescribing outcomes for this vulnerable population.     

The drive for quality care in US nursing homes in the era of the prospective payment system

The quality of nursing home care has often given rise to concern from many interested stakeholders. In the US, this has led to the implementation of a major legislative framework in the form of the Nursing Home Reform Act, which sought to improve the quality of care through regulation and inspections. Research has shown that certain elements of care have improved but much remains to be done. Additional pressure is now being placed on the nursing home sector through the introduction of a prospective payment system (PPS), which sets limits on reimbursement for services for Medicare-covered stays. It has been proposed that this new system of payment may lead to difficulties in accessing nursing home care for patients who are deemed to be costly, and initial assessments suggest that patients are now carefully screened before being admitted to nursing homes. This may have major implications for patients who require multiple and expensive drug therapy and other interventions. Although the Nursing Home Reform Act seeks to drive forward the quality agenda in nursing home care, research is urgently required to evaluate the impact of the PPS which may force this healthcare sector to emphasise reducing costs at the expense of residents' needs.     

An assessment of pharmaceutical inspection reports from nursing and residential homes for the elderly in Northern Ireland

Objectives To highlight issues currently being inspected in nursing, residential and dual‐registered homes (care homes) for the elderly in Northern Ireland as part of a pharmaceutical inspection. Methods A cross‐sectional survey and analysis of reports from pharmaceutical inspections in Northern Ireland care homes between January 1999 and December 2000 was undertaken, using reports provided by the four Registration and Inspection Units (R & I Units 1–4) within the region. Reports were reviewed and all recommendations made by inspectors were classified into 11 main categories. Binary logistic regression was used to examine possible relationships between the type of home (nursing, residential or dual‐registered) or the R & I unit and the recommendations made by the inspectors, with corresponding odds ratios and 95% confidence intervals. Key findings Reports from 415 homes (one report per home) formed the final sample for analysis. Each R & I unit used different documentation to conduct a pharmaceutical inspection. Homes received the majority of recommendations from inspectors in the categories ‘Records’ (66.7% of all homes), ‘Policies and protocols’ (39.3%) and ‘Medication’ (31.8%). More recommendations in a number of categories emanated from R & I unit 4 compared with R & I unit 1 (referent). Dual‐registered homes (those registered as a nursing and residential facility) were more likely to receive a recommendation in the categories ‘Storage of medicine’, ‘Order and receipt of medication’ and ‘Equipment’ than nursing or residential homes. Conclusion Inspections of care homes should be standardised in terms of documentation used and facilities should be given guidance on issues that are likely to result in recommendations from inspectors. In the longer‐term, pharmaceutical inspections should move from a focus on structure/process measures to those that emphasise quality in prescribing.     

Measuring care and dependency of elderly people in residential homes: an unreliable exercise.

OBJECTIVES: to determine the correlation between a scale measuring the amount of care required by people in rest homes and two scales, the Booth scale and the composite scale which measure dependency. To examine the scales for retest reliability. SUBJECTS: one hundred and twenty-five people aged 47 to 98 years, median age 84 years, living in seven rest homes in Dunedin. METHOD: subjects were assessed using the care, Booth and composite scales and the assessment repeated after four weeks. RESULTS: the care scale test-retest reliability based on rank order correlates was 0.86. For the physical care items retest reliability was high but supervision and the management of behavioural problems showed poor retest reliability. Correlation between the care scale and the two dependency scales was only moderate (composite scale 0.64, Booth scale 0.55). Behavioural problems and the time for supervision were assessed on the care scale only and it was these components which accounted for most of the poor correlation between the care and dependency scales. CONCLUSION: the time required for the management of behavioural problems and supervision for some people in rest homes was considerable. Measurement of this was difficult and made assessment of individual residents in homes unreliable.     

Multidisciplinary medication review: evaluation of a pharmaceutical care model for nursing homes

Objective The objective of this study was to assess implementation of a pharmaceutical care model for the multidisciplinary care of elderly patients in nursing homes. Setting Prospective study, medication review, from January 2007 to December 2009 in ten nursing homes affiliated to the Pharmacie interjurassienne (PIJ), Switzerland. Method Medication use data were collected and reviewed by a pharmacist, focusing on drug indication, dosing, side effects, renal/hepatic elimination and interactions. Drug-related problems (DRPs) were discussed face-to-face with the responsible physician and a nurse. The pharmaceutical care issues were formulated and medication interventions proposed during this meeting. DRPs and interventions were documented using the Pharmaceutical Care Network Europe scheme version 5.00 (PCNE V5.00). The economic impact of the service was estimated through a retrospective evaluation of annual drug costs. A satisfaction evaluation was conducted among practitioners and nurses. Main outcome measures DRPs, interventions, treatment changes implemented. Results Drug therapy of 329 patients was reviewed. The number of medicines per patient ranged from 2 to 27 (mean 12.8). A total of 1,225 DRPs were detected and discussed with the physician and the nurse. Medication review led to 343 medical evaluations secondary to drug-drug interactions and 803 treatment adaptations: 373 drugs were stopped, 197 dosages changed, 95 instructions for use amended, 86 drug choices were altered, 35 drug formulations changed and 17 new drugs started. According to the Anatomical Classification System, the main classes involved in interventions were related to Alimentary tract and metabolism (n = 285), Nervous system (n = 189) and Cardiovascular system (n = 115). Since the outset of the PIJ, the annual drug costs decreased in nursing homes with medication review including a pharmacist, whereas it was stable in the other nursing homes. The satisfaction evaluation showed a very positive appreciation by practitioners and nurses. Conclusion The study showed an efficient pharmaceutical care model, well accepted by physicians and nurses. It also indicated that for elderly patients, continuous drug review contributed to improved drug therapy, reduced unnecessary polypharmacy and reduced pharmaceutical costs.     

Assessment of a United States pharmaceutical care model for nursing homes in the United Kingdom

Objective

To assess the suitability of an American model of pharmaceutical care for nursing home residents (The Fleetwood model) for application in nursing homes in the United Kingdom.

Method

Pharmacists (those from a hospital setting or involved in prescribing support), general practitioners, nursing home managers and advocates for older people were invited to participate in semi-structured interviews or focus groups. The American Fleetwood model was explained to all participants who were asked for their views and opinions on how such a model could be adapted for use in the UK setting. All interviews and focus groups were tape-recorded, transcribed verbatim and analysed using the framework method.

Main outcome measure

An adapted model of pharmaceutical care for use in UK nursing homes.

Results

There was general concern about prescribing in nursing homes, particularly in relation to psychoactive drugs. All participants were supportive of the proposed model of care and endorsed the greater involvement of pharmacists. However, participants also recognised that unlike pharmacists in the US nursing home setting for which the Fleetwood model had been developed, pharmacists implementing this approach in the UK would face major challenges in relation to access to records (medical and medication), prescribers and residents.

Conclusion

The findings highlighted the key elements of access which will need to be considered if this model of pharmaceutical care is to be applied to nursing home residents in the UK.

Impact of findings on practice

The model has been revised to take account of the challenges relating to access and will be tested in a randomised controlled trial.

     

Assessment of a United States pharmaceutical care model for nursing homes in the United Kingdom.

OBJECTIVE: To assess the suitability of an American model of pharmaceutical care for nursing home residents (The Fleetwood model) for application in nursing homes in the United Kingdom. METHOD: Pharmacists (those from a hospital setting or involved in prescribing support), general practitioners, nursing home managers and advocates for older people were invited to participate in semi-structured interviews or focus groups. The American Fleetwood model was explained to all participants who were asked for their views and opinions on how such a model could be adapted for use in the UK setting. All interviews and focus groups were tape-recorded, transcribed verbatim and analysed using the framework method. MAIN OUTCOME MEASURE: An adapted model of pharmaceutical care for use in UK nursing homes. RESULTS: There was general concern about prescribing in nursing homes, particularly in relation to psychoactive drugs. All participants were supportive of the proposed model of care and endorsed the greater involvement of pharmacists. However, participants also recognised that unlike pharmacists in the US nursing home setting for which the Fleetwood model had been developed, pharmacists implementing this approach in the UK would face major challenges in relation to access to records (medical and medication), prescribers and residents. CONCLUSION: The findings highlighted the key elements of access which will need to be considered if this model of pharmaceutical care is to be applied to nursing home residents in the UK. IMPACT OF FINDINGS ON PRACTICE: The model has been revised to take account of the challenges relating to access and will be tested in a randomised controlled trial.