Pharmacy services for the “oldest” old

Maria Veart 150x150By Maria Veart MRPharmS, Research & Clinical Pharmacist, Hospital@Home, NHS Fife

Given the choice I imagine that most elderly patients would prefer to stay in the comfort of their own home and be treated there when ill, with friends and family close by, rather than be admitted to hospital. Now, thanks to a project in NHS Fife 80% of elderly patients in this area are able to receive hospital-like treatments in their own home.

Managed by the Hospital at Home  team across all Community Health Partnerships (Kirkcaldy and Levenmouth, Dunfermline West Fife and Glenrothes North East Fife) the service provides acute, hospital-like treatments to patients over 75 who need a more intensive clinical input, investigations and monitoring than community and GP services are able to provide, but all the while ensuring the patient can remain at home.

It involves comprehensive geriatric assessments with consultant-led teams consisting of experienced nurse-practitioners, community nurses and allied healthcare professionals and health care assistants. The patient will be treated in their home for an average of nine days, with reasons for admissions including infections, exacerbations of COPD and heart failure, dehydration, delirium, falls, metabolic disturbances, and reduced mobility.

Projects such as this are vitally important as we address the needs of an ever-growing older population. According to the World Health Organization the 85-and-over population is projected to increase 351 per cent in the period 2010 to 2050. Scotland follows this trend. The number of people over 85 is forecast to more than double over the next 40 years. Hospital at Home and similar services around the country hope to therefore address the increasing needs of the “oldest” old- the fastest growing part of the population.

The pharmacist’s role in this service is crucial. The spectrum of pharmaceutical needs is broad; often patient’s medication use involves self-administration of oral medication and acute therapy, which may include IV drugs administration by nursing teams. As part of the service the pharmacy team offers home visits which provide a valid opportunity to engage with patients and their families in their own environments- focussing on problems that matter to them.

When visiting patients’ homes we see another side to polypharmacy and over-prescribing- the alarmingly high amount of unused medicines being stockpiled at many homes. The service is therefore another way for us to directly manage these issues. The reasons for non-adherence among the frail and disabled patients are complex and multifactorial. Inability to take medication is often linked to dementia, depression, decreased manual dexterity and lack of social support. Many of these problems can only be resolved in close cooperation between healthcare teams and families, carers and social care.

An “optimal” pharmacy model would incorporate a single point assessment of medicines-related needs for all frail patients who come into Hospital at Home services. Where patients with difficulties in taking medication and polypharmacy have been identified, they should be referred to pharmacy teams that, with efficient resources, resolve and coordinate care in relation to the patients’ medication.

The great challenge, as for many other pharmacy practitioners, is to re-align pharmacy service development to address modern trends in society and healthcare within very limited resources. Among many competing activities that pharmacy teams are engaged in, the objective is to focus on tasks that are highly valued by patients, members of the healthcare teams and have demonstrated meaningful clinical outcomes. This may be different from our traditional views on pharmacy roles and priorities.