Transcript Dementia Action Alliance Our goal

The Right Prescription
A Call to Action on the use of
antipsychotic drugs for people with
dementia.
Catherine Holmes
Our goal
By 31st March 2012:
• all of the estimated 180,000 people with dementia who are
receiving antipsychotic drugs will have undergone a clinical
review , to ensure that their care fits with current best
practice and guidelines and that alternatives to their
prescription have been considered
• People with dementia are not prescribed antipsychotics in
future unless their situation fits the guidelines
The challenge
There is a lot of activity and
energy for change.......
Unless that energy is translated
into appropriate prescribing
and appropriate review of
medications, it counts for
nothing
We want to provide a focus and
direction that moves everyone
in the same direction
What did we need to agree?
• Who we are calling to
action
• What actions we want
them to take
• The sources of support
and resources that will
be made available to
help them in their
actions
Eight groups to call to action
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People with dementia and their carers
Leaders of care homes
GPs and primary care teams
Psychiatrists and mental health teams
Pharmacists
Hospital doctors and their teams
Commissioners of health and social care
Medical Directors and Nurse Directors of acute and
mental health trusts/providers
COMMITTMENT FOR GENERAL PRACTICTIONERS AND PRIMARY CARE TEAMS
Specific commitment?
GPs commit to identify and
review their patients who have
dementia and are on
antipsychotics with the
purpose of understanding why
antipsychotics have been
prescribed.
Working in partnership with
the person with dementia,
their family and carers and
their medical colleagues in
psychiatry to establish whether
or not
the use of antipsychotics is
inappropriate and whether or
not it is safe to begin the
process of discontinuing their
use and to establish that access
to alternative interventions can
be secured
Main themes for action?
Undertake audit of accuracy of practice registers.
And review of prescribing decisions
Identify who is on repeat prescriptions and review
timescales in place.
Develop an understanding of the alternatives, the
evidence base for these and their availability locally
.Put referral processes in place- e.g. memory clinics
Resources/sources of help ?
National standards & recommendations
for review and withdrawal of
antipsychotic drugs and nonpharmaceutical alternatives.
Guidelines for Care Homes and Nursing
Homes (example from Medway) & Skills
for Care guidance.
Awards for good practice including
Cornwall STAR (challenging antipsychotics
and commissioning in dementia, via Martin
Freeman) [email protected] )
.
Work in partnership with other colleagues
(psychiatrists, pharmacists, care home leaders) to
develop a mutual understanding of the existing
issues and develop a planned review for people
with dementia who are on antipsychotics –to
include specific support around the withdrawal of
antipsychotics.
Discuss patients/families/carers’ expectations
around prescribing – what people think they want.
Prescription guidelines authored and
owned by all partners (example
available from Medway [email protected]
Link with the Coroner’s office- avoidable
deaths.
Script switch messages for use in
practices-prescribing software and AP
alerts
Using practice based communicationsleaflets, RCGP good practice with carers
COMMITTMENT FOR GENERAL PRACTICTIONERS AND PRIMARY CARE TEAMS
continued…
Main themes for action?
GPs commit to identify and
review their patients who have
dementia and are on
antipsychotics with the
purpose of understanding why
antipsychotics have been
prescribed.
Working in partnership with
the person with dementia,
their family and carers and
their medical colleagues in
psychiatry to establish whether
or not
the use of antipsychotics is
inappropriate and whether or
not it is safe to begin the
process of discontinuing their
use and to establish that access
to alternative interventions can
be secured
Audit who is on Aps•Diagnosis
•Under review
At riskCare plan for. people at risk
Appropriate use of medicines and alternatives.
Focus on admission prevention
Communication
Secondary care at discharge-identifying post
discharge support.
Improved information in community regarding
relevant life history to know the pt.
Primary to secondary care passport.
Resources/sources of help?
Pharmacy/non pharmacy interventions.
Holistic assessment carers/families
Predictive modelling
Appraisal
revalidation,
QoF,
Qipp,
CQuin
Carers/families questionnaire
Hospital Passport
Reminiscence.
Community Matrons
Environment/co-working.
Resources and mapping of non-pharmacy
alternatives.
Use of personal budgets
Business case development for investment in
alternatives for commissioners
Medicines Management Team
Admission prevention teams
Third sector
Social services
)
Holistic assessment -Interia project
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Map of medicine
COMMITTMENT FOR COMMISSIONERS IN HEATH, SOCIAL CARE AND GP COMMISSIONING
Specific commitment
Main Themes for action
Resources/sources of help?
Needs Assessment
Joint Strategy Needs Assessment and Health & Wellbeing Strategy (and wider strategic
plans) demonstrate the needs of people with dementia and carers by including
residential care standards, workforce capacity & capability, health promotion and
prevention and safeguarding protocols.
I (we) commit to:
1.Improving the quality and
experience of care for people
with dementia ( and their
carers) ,by commissioning a
whole systems approach to
dementia
2.. Ensure through effective
evidence-based
commissioning, we support
providers to minimise the
need for antipsychotic drugs ,
and in addition to ensure
prescribing is in line with
NICE guidelines across the
health and social care system
Needs Assessment/Priority setting
All localities to take local audits (using available / shared audit tools) of current practice
for antipsychotic prescribing medication for people with dementia which covers the
whole health and social care system by 31st March 2012 Commit to change local
commissioning plans as appropriate and contracts with all partners to reflect this and to
reduce antipsychotic prescribing. measured by:
- the lens of people with dementia and their carers
- professional behaviours/practice
- actions at an organisational/system level
Commissioning pack to include SCIE recommendations
Recommended reading / information prescriptions (see
appendix 1)
Audit results and statistics with examples and key questions
to ask of the audit data e.g. % prescriptions generated in
secondary care, no of pts on anti-psychotics with no
diagnosis, what % people in care homes have had no review
in last 6 months, what are prescribing stats in primary care,
what is the incidence of falls reported from people with
dementia on anti-psychotics.
Examples of good practice include:
SE Collaborative – audit and quality indicators
Surrey – whole systems model inc Telecare
Commissioning specifications and contracts which reflect interventions and functions
which deliver outcomes which minimize the need for anti-psychotics.
Service review/Priority setting
Ensure local plans are in place by 31/3/12 to deliver the national dementia strategy
specifically anti psychotic prescribing. Publicize and promote this plan and ensure is
accessible and understandable by the public
Commissioners to make dementia business as usual across all areas of commissioning.
Commissioners to develop and enhance leadership and governance for prescribing.
Service redesign and supplier side reshaping
Enabling providers with MDT to use appropriate alternatives to prescribing by strong
evidence based commissioning in all areas ( this is the primary responsibility of the
doctors but a part of the commissioning ethos). Ensure ‘in reach ‘ services appropriate to
your locality is a priority within commissioning intentions. Incorporate within primary,
acute, mental health and care home contracts governance mechanisms for regular audit
of anti-psychotic prescribing. Implement NICE compliant protocols between primary and
secondary care for the review of anti-psychotic medication on patient transfers.
Local and national publications (see appendix 1). Dementia
portal / NHS Networks – dementia section
“This is me” Alzheimer's society
“Misspent opportunities” audit commission
Compendium of good practice and success stories/case
studies , including those alternative approaches
Set up a steering group to share good practice
Create a central place to collate information – National Field
or dementia portal.
Reference and link to websites which contain to partnerships,
protocols for good practice.
Local QOF data with up to date information Link to QIPP and
Clinical Decision making
Monitor and implement an MDT and multi-agency process for serious untoward
incidents associated with people with dementia and their carers
Workforce development
Education commissioned for the public, workforce and managers enabling each to gain
key skills to improve outcomes. Setting key educational stds for people in the health &
social care , independent sector workforce , working with people with dementia .
Enabling provision of training for lay carers
QOF data / LES CQuINs. CQC.
Link to specific web pages and key documents which support
commissioning decisions
COMMITTMENT FOR LEADERS OF CARE HOMES:
Specific commitment
Main themes for action
Review processes and infrastructure which may lead to
inappropriate prescription of antipsychotics and put in
place other systems to support best practice (See slide
2: Sub-themes for action arising from this).
Resources/sources of help
National Dementia Strategy
Guidelines from Alzheimer’s Society
Guidelines from Dementia Alliance
NICE and SCIE Guidelines
Develop/put in place a proactive, systematic register for
maintaining and monitoring all antipsychotic
prescriptions, reviews and outcome decisions.
I (we) commit to:
Identifying all people
prescribed antipsychotic
medication and to
documenting and delivering
an evidence-based,
personalised care-plan
developed in partnership
with the individual, their
family & the multidisciplinary clinical team
Undertake a home-wide review of prescriptions initially
& then establish a system of proactive review for all
new residents, upon taking up residence, and
thereafter in line with current clinical /best practice
guidelines.
Establish clear relationships with, and links in to,
emerging collaborative partnerships between GPs and
Pharmacists - establishing as part of the wider call to
action.
Develop clear, systematic protocols to ensure support
to care home staff in actively challenging antipsychotic
prescribing.
Develop clear, systematic information resources &
support for use by the individual, their family and care
home staff
Provide access to dementia-specific training &
development opportunities for all care home staff.
Multi-disciplinary care pathway:
management of challenging behaviour
Department of Health: compendium of
best practice
(Examples of non-drug alternatives)
BUPA Mental Capacity Act ‘postcard’ for
staff
SCIE Dementia Gateway
Social Care TV
Charities Websites
Social Media (e.g. Facebook): BUPA,
Dementia UK, possibly others
Care UK: Experiential Learning Course
(Surry Pilot)
BUPA: How to work with challenging
individuals
BUPA: Understanding behaviour (partnered
with Bradford University)
Alzheimer’s Society: Focused Intervention
Training for Staff (FITS 10-day programme)
Boots: Dementia Medication Training
ElBox, SKIP, MABO, Studio 3 & Edge
COMMITTMENT FOR LEADERS OF CARE HOMES: (Continued)
Key Theme for Action
Sub-themes for action
Identify a named ‘Dementia Champion’ in each care
home, supported through appropriate specialist
education and training, with sufficient authority to
effect change.
Identify and utilise personal information resources for
use by the individual, their family and care home staff.
Review processes and
infrastructure which may
lead to inappropriate
prescription of
antipsychotics and put in
place other systems to
support best practice
Provide the times and resources for recognised
accredited training on good dementia care.
Build relationship with the community to put in place
interventions in the care home in line with best
practice.
Resources/sources of help
Tools to help in the care environment
e.g. Dependency scoring template
Flowchart for recognising problems which
could change behaviours
Observational tools
SCIE website, gateway &social care TV
Training resources
e.g. Training DVDs
Resident experience training
Motivational mapping tools
Voluntary sector - Alzheimer’s Society
training and resources
E-learning resources
Medicines management training
Sources of support/service other than
antipsychotics
e.g. Alternative therapies and activities
Local memory clinics
Environmental resources - e.g. Eden
Journal of dementia care
Health and social care professional support
Provide ongoing training and support to staff.
Establish and maintain a clear relationship with
multidisciplinary team members (e.g. GPs and
pharmacists).
Care plan
The individual, their family and carers
e.g. This is me document/Dementia
passport
Examples of good practice
e.g. Nothing ventured, nothing gained DH
doc
DH Compendium of best practice
COMMITTMENT FOR PHARMACISTS
Specific commitment?
Main themes for action?
Resources/sources of help ?
Establish a clear dialogue and agree joint working
practices for reviews with all prescribing partners
Guidance in Bannerjee report
Source of specific guidance from RCGP
Become better informed about best practice guidelines
for the prescribing of antipsychotic medication, and
alternative interventions, for people with dementia.
Provide support and sign-posting to alternative resources
for people with dementia and their carers
http://www.rcpsych.ac.uk/files/pdfversion/
CR138.pdf
http://www.rcpsych.ac.uk/files/pdfversion/
cr119.pdf (see section 8 and appendix)
I (we) commit to:
Reviewing the people under my
care to identify those who are
prescribed antipsychotic
medication and to work in
partnership with my prescribing
and other health care colleagues
to review each individual by 31st
March 2012
Community pharmacists:
Query every prescription for an antipsychotic for people
aged 65 years or over and/or those known to have
dementia and search for, and audit, all people 65 years
and over who have received antipsychotic medication in
the last 3 months
Hospital pharmacists:
Query every prescription for an antipsychotic for people
aged 65 years and over and ensure that discharge
information is up to date regarding the actions GPs
should take (in line with NICE guidelines)
All antipsychotic are flagged on transfer documentation
with a clearly identifiable review date PCT and
commissioning pharmacists:
Include antipsychotic within QOF action plan and QIPP
target. Review/challenge high prescribers
Report back on my progress in these activities
Guidelines from Alzheimer’s Society
Guidelines from Dementia Alliance
Talking with people with dementia and
their families
NICE and SCIE guideline
Multi-disciplinary care pathway –
management of challenging behaviour in
dementia
Department of Health – compendium of
best practice
(Examples of non-drug alternatives)
COMMITTMENT FOR PSYCHIATRISTS AND MENTAL HEALTH TEAMS
Specific commitment?
Main themes for action?
Resources/sources of help ?
To challenge routine practice and update
knowledge base using current evidence and best
practice
Utilise clinical governance esp. clinical audit, to
provide information on local practice to inform
required local action
I (we) commit to: Review the
causes(s)
of disturbed
Review the
causes(s) behaviour
of
before
initiating
or
continuing
disturbed behaviour before
antipsychotic
treatment
initiating or continuing
antipsychotic treatment
Offer local education opportunities to all
psychiatrists and to all hospital doctors
NICE guides for dementia
Royal College Psychiatrists resource
pack
‘Getting to Know You’ charts – to help
identify causes of disturbed behaviour
Increase links and offer educational support to Care
Homes e.g. 1 day conference with input from
psychiatrists and care homes staff
Annual mtg of Faculty of Old Age
Psychiatrists / Royal College (March
Increase links with local GPs esp. identifying and
working with GP 'dementia leads’ to review local
practice
Flowchart for identifying causes of
BPSD – Anne Child. [email protected]
mtg– but could utilise newsletters)
RAGE for monitoring
Joint visits (psychiatrist and GP) to ‘struggling’ care
homes (possibly monthly)
Patients discharged on antipsychotic treatment to
have a clear management plan and support from
the Care Home liaison team
Admission process pathway – North
Staffs (audit data to demonstrate
benefits)
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COMMITTMENT FOR PEOPLE WITH DEMENTIA, THEIR CARERS AND FAMILIES
Specific commitment
Main themes for action
Resources/sources of help
Care plan and ‘who I am‘ document (e.g.
This is me, Dementia Passport)
Seek information and support from the voluntary
sector and other resources on treatment and care
options and seek guidance on how to establish a
dialogue with health and social care professionals.
I/We commit to
Proactively seeking a
conversation with my (our)
GP to review care and agree a
personalised care plan (in line
with best practice)
Take responsibility for sharing insights into who I
am and what I want (who the person I care for is
and what they want) to support the development
and implementation of an effective, valuable and
realistic care plan.
Take responsibility for working in partnership with
care team to ensure initial and ongoing
appropriate review of the care plan.
Information from the voluntary sector (e.g.
Alzheimer’s Society’s antipsychotics
booklet, Alzheimer’s Society website, Age
UK website).
Local services and peer support networks
(e.g. Memory clinic, dementia adviser,
support group).
Information from membership
organisations such as UKHCA and ECCA
Non-web information sources (e.g.
Alzheimer’s Society help lines, libraries)
Local and national media
Health and social care professionals (e.g.
GP, CPN, consultant)
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