ServiceLevelAgreementfora LocalService for theProvision ofDomiciliaryMedicine UseReviews

Pleasenotethatfor this servicewill becommissioned for a limited number ofpatientsinitially10(TEN) patientsper pharmacy.Pharmacies thatwishtoprovidethis service tomore patientswill need toobtainwrittenagreementfrom Samantha Travis, Clinical Leadership Adviser prior toconductingany additional reviews.

1.1 Service level agreement

This agreement is between

NHS England North Midlands (the Commissioner)

Birch House, Southwell Rd West, Rainworth, Notts, NG210HJ

And the Provider:(“the pharmacy”)

Trading as:

Address:

Contractor ODS code: F

Purpose

ThisSLAhasbeendevelopedfor theprovisionofMedicine UseReviews in the homesettingrather thanin thepharmacyfor long term conditions patients who are houseboundand thoseunabletoattendthepharmacyfor a review, who are taking six medicines or more, torun from 01 April 2017 – 30 September 2017.

Period

This agreement is for the period 01 April 2017 to 30 September 2017

Termination

One months’ notice of termination must be given if the pharmacy wishes to terminate the agreement before the given end date.

NHS England North Midlands may suspend or terminate this agreement forthwith if there are reasonable grounds for concern including, but not limited to, malpractice, negligence or fraud on the part of the pharmacy.

Obligations

The pharmacy will provide the service in accordance with the specification below.

NHS England North Midlands will manage the service in accordance with the specification.

Payments

NHS England North Midlands will pay the following:

£56 foreachdomiciliaryMUR in addition to the MURpayment.

MURpaymentswill bemade accordingtothenational service–currently£28per consultationandwillbeclaimedfor through PPD.

Payments will be entered on to the NHS BSA Local Payments Application and will appear on pharmacy contractors’ monthly statement from the NHS BSA.

Standards

The service will be provided in accordance with the standards detailed in the specification below.

Confidentiality

Both parties shall adhere to the requirements of the Data Protection Act 1988 and the Freedom of Information Act 2000.

Any approaches by the media for comments or interviews must be referred to NHS England North Midlands.

Indemnity

The pharmacy shall maintain adequate insurance for public liability and professional indemnity against any claims which may arise out of the terms and conditions of this agreement.

Any litigation resulting from an accident or negligence on behalf of the pharmacy is the responsibility of the pharmacy who will meet the costs and any claims for compensation, at no cost to NHS England.

1.2Service specification

1.2.1 Aims

  • Toimprove the patientsunderstanding oftheirmedicines and whythey are taking them
  • Toimproveadherencetomedicationbyputtingin placesystems to support adherencewhere needsare identified
  • Toimprove access tomedicines byputtinginplacesystemsforthe ordering/collectionofprescriptions /delivery of medicines where needs are identified
  • Tousetheexpertiseandknowledgeofpharmacistsontheuse of medicines toreducetheincidence ofadverse drug effects
  • Toreducewastageof medicines
  • Todisposeofmedicines nolonger required
  • Tolookatsipfeed orderingandusageandcheck thepatienthasan ongoingneed
  • Toproducemeasurable outcomesonthelikelyreductions in emergencyadmissionsas aresult oftheinterventions made
  • Toidentifyissues associatedwithhighriskmedicines
  • Toinform futuredevelopmentsinpharmaceutical servicestothe houseboundpopulation.
  • Theserviceis NOTintendedtobea means simplyto transfer patients ontoMonitoredDosage Systems,unless deemednecessaryfollowing aseparateDDA assessment
  • Theserviceis NOTintendedtobeused for patients in care home settings who are unable to self-administer their medicines

1.3Service elements

  • Identification of eligible people
  • Arrangementofhomevisit
  • Provision oftheMUR andatperson’shome
  • Recording ofMUR andadditionalassessment and other outcomes/findingsandscoringusing the amended RIO system on PharmOutcomes
  • SIPfeeds- ensurearecentassessmentforongoingneedhas been performed.Wherepatientsare eatingnormallysuggestsipfeed discontinuation.
  • Waste avoidance - ensure patientonlyorders whatis neededoneachrepeat prescription
  • Disposal of unwantedmedicines

It is vital that any actions you take to improve patient adherence are recorded on the PharmOutcomes system to inform future commissioning decisions regarding this service.

1.4Eligibility

AllNamedPharmacists providingtheservice:

  • Must be accredited toprovide MURs
  • NHS England,North Midlands permissiontocarryoutdomiciliaryMURsas partoftheproject must be sought.
  • Each pharmacyshouldsubmitaPREM2Cformforthis purpose- specifying“patients referredunder theDerbyshire/ NottinghamshireDomiciliaryMURProject” as thecategoryof patient, and“patients ownhomes” as thelocation.
  • Currentenhanced DBScheckis required prior tocommencement (dated within 2 years)

Pharmacy

Servicelevel agreementsignedby namedpharmacist responsiblefor the service on behalfofthe pharmacyand alsosigned by NHS England,North Midlands

Service users:

  • RegisteredwithaDerbyshire or NottinghamshireGP
  • Agrees topharmacist visitingat home
  • Taking 6 or more medicines for one or more long term condition

Pleasenotethatfor thisservicewill becommissioned for a limited number ofpatientsinitially10(TEN) patientsper pharmacy.Pharmacies thatwishtoprovidethis service tomore patientswill need toobtainwrittenagreementfromSamantha Travis, Clinical Leadership Adviser prior toconductingany additional reviews.

2.1Identification of eligiblepeople:

Peopleshouldbelivingin theirown homes (notacarehome)and,save for exceptional circumstances,notreceivingformal support with theirmedicines administrationfromacarer.Wherepeopleare known tobeinreceiptof supportfromadomiciliarycare agency,thepharmacist shouldascertainthat this does notinclude medicationadministrationfor someor alloftheir medication.

Peopleshouldbeunabletoattendthepharmacyfor anMUR.

Patients can self-refer, be identified as suitable by GPs, pharmacists and their staff, by carers or by secondary care professionals.

2.2Arrangementofhomevisit

Theperson’s GP should becontactedfirsttoconfirm thatthere arenoknown risks to thepharmacist visitingthis person athome.

Contactshouldbemadewith theperson,either bytelephoneor letter andthe medicines usereview explainedand offeredto thepersonattheir home. Relatives or carers canbepresentifrequested bytheperson.

A suitabletimeshouldbe arrangedforthepharmacisttovisittheperson at homefor theMUR andadditionalassessment.

Othermembers ofthepharmacyshouldbeinformedofthe time,locationand expectedduration oftheMUR. Amobilephoneshouldbecarriedbythe pharmacist whenvisitingtheperson’shome.

Smartcardsshouldbe used as identification,alongwitha letter of authorisationtoprovide theservicefrom the Area Team,whichshouldbeshown tothe personbefore enteringtheir home.

2.3TheMUR and additionalassessment

The aims oftheMURare:

  1. To establishthepatient’s actual use,understandingand experience oftakingdrugs;
  2. Identifying, discussingandassistingin theresolution of pooror ineffective useofdrugs bythepatient;
  3. Identifyingsideeffectsanddruginteractions thatmayaffectpatient’s compliancewith theinstructions given byahealthcare professionalfor thetaking of drugs; andimprovingtheclinical andcost effectivenessof drugs prescribedtopatientstherebyreducingthewastageofsuch drugs.
  4. Any self-care / lifestyle advice should be noted also
  5. If the patient was signposted or referred to any other local services we would like to collect this information

PleasenotethattheMURserviceis intendedonlytolookattheuse of medicines andclinical interventionsare notexpected. However, the pharmacist will be expected to indicate where they have recommended a particular medication is stopped / removed

from repeat, where it is identified that there is a build-up of unused / waste medicines.

We would also like to capture any other outcomes or positive patient stories which may result from your visit – results of inhaler technique checks etc / was a recommendation for a formulation change acted upon, for example.

Theaims oftheadditional assessmentare:

  1. Toidentifyanyissues thepatienthas inaccessingtheirmedicines– orderingandcollectingprescriptionsandcollectingmedicinesandto putinplacesupporttoaddressthese
  2. Toidentifyanyphysical issues thatthepatientmayhave thatimpacton theirabilitytotaketheir medicines andhowtominimisethese by changingeitherformulation,packagingor labelling, or provisionofan aidsuch asaneye drop dispenseror spacer
  3. To assessanycompliance aidscurrentlyusedbythepatienttohelp them toremember totaketheirmedicinesand toidentifyand provide anysupporttoassist with this suchas reminder charts,medicine administrationrecords.
  4. Todetermineifthepatientiseating normallyor hashadarecent assessmentforongoingneedofsipfeeds.

Anyproposedchangestomedicationasaresult oftheMUR or additional assessmentshouldbediscussedand agreed with the person’s GP.On implementationofanychanges tomedication,thepharmacist should ensure thatsufficientcommunicationis suppliedto the personandalsoanyrelatives or carers.

2.4Documentation ofMUR and additionalassessmentand scoring using amended RIO scoring system

Thestandard MUR documentationshouldbecompleted andpayments for the standard MUR feeclaimedfor in thenormal way (FP34). In additionthepharmacist shouldconducttheadditional assessmenton PharmOutcomescoveringaccess issues,physical issues compliance aidsandsip feeds.

The project usesascoringsystembasedonRIOwhichclassifiesthe interventionaccordingto thelikelyeffecttheinterventionhasonpreventinga hospital admission.

RIO1= nolikelihoodofemergencyhospitaladmissionprevented

RIO2= possible prevention of emergencyhospital admission

RIO3= likelyto preventanemergencyhospital admission

This will enableaquantitative evaluation ofthis projectinrelationtopatient outcomes. TheamendedRIOscoringshouldbecompletedon theadditional assessmentformandalso added to the MUR formwhereinterventions have beenmade ofRIO2 or RIO 3.

AnanonymisedsummaryofeachMURandadditional assessment,bothwith RIOscoringcompleted,will need to beentered ontoPharmOutcomes,this informationwill be used toassessthesuccess oftheprojectandwilltrigger paymentofthedomiciliaryfeetothepharmacy.

2.5Audit of service

The pharmacy participates in any NHS England, North Midlands led audit of service and

agrees to provide a minimum of 3 brief patient experience stories, or descriptions of how patients have benefitted from their intervention during the duration of the service on request.

2.6Waste avoidance

Anelementofthis enhancedservicewill be directedatreducing unnecessary waste.Thismaybeduetomedicines being orderedwhich are nolonger required.Alternativelymedicinesmaybe ordered in excessivequantities or morefrequentlythanis requiredandbeforeprevious supplieshavebeen used.

Pharmaciesprovidingthis enhancedservicewillbe expectedtoparticipatein reducingmedicines waste.Thepharmacist shouldask toseeallsupplies of medicationand proactivelyquestion anyapparent over-ordering ofmedicines e.g.inhalersorderedmonthly, excess quantities of external preparations, dressings,whenrequiredmedicines andsipfeeds.

Thenumber ofwasteavoidanceinterventions which are attributableto this domiciliaryMUR serviceshouldberecordedonPharmOutcomes alongwitha brief description oftheinterventionso thatcostsavings maybecalculated. This will helpinformfuture decisions ontheviabilityoftheservicegoing forward.

2.7Disposalof unwanted medicines

Thepharmacist shouldoffertodisposeof anyunwantedmedicines.Any medicines takenfor disposal shouldbeentered ontothedisposal of medicationformandthe person askedtosignthis beforethemedicines are removed. Theinformationshouldbeaddedto PharmOutcomes after returningtothe pharmacyso thatcostsavings maybecalculated.This will helpinformfuture decisions on theviabilityoftheservicegoingforward. Pharmacists areremindedtocarryappropriate disposal equipmentwith them whencarryingoutthe MUR.

2.8Payment

Pharmacieswill bepaid£56for eachdomiciliaryMURconductedaccordingto theservicespecification.Inordertoclaimthis payment, fulldetails ofthe anonymisedMURform, additionalassessments,sipfeeds,wasteissuesand anymedicines disposedofshouldbeenteredontoPharmOutcomes.The invoiceis generatedbythePharmOutcomessystem.This paymentis in addition tothenormalpaymentsfor MURs whichshouldbeclaimedfor inthe normal way.

Pleasenotethatfor this servicewill becommissioned for a limited number ofpatientsinitially10patientsper pharmacy.Pharmacies thatwishtoprovidethis service tomore patientswill need toobtainwrittenagreementfromSamantha Travis, Clinical Leadership Adviser, prior toconductingany additional reviews.

2.9Outcomes

Aim of service / Measurementof outcome
Toimprove access tomedicines by
puttinginplacesystems for the ordering/collectionofprescriptions / deliveryof medicineswhere needs areidentified / Informationenteredonto
PharmOutcomes about additional assessmentscarried out.
Toimproveperson’sunderstanding
oftheirmedicinesandwhytheyare takingthem / Datafrom anonymisedMURs
enteredontoPharmOutcomes
Toimproveadherenceto medication byputtingin placesystems to support adherencewhere needsare identified / Informationenteredonto PharmOutcomes about additional assessmentscarried out.
Tousetheexpertiseandknowledge ofpharmacists on theuseof medicines toreducetheincidence of adverse drug effects / Datafrom anonymisedMURs enteredontoPharmOutcomes
Toreducewastageof medicines / Informationenteredonto
PharmOutcomes about amountand estimatedcost of medicines waste avoided asaresult ofthe intervention.
Toreduceunnecessary
prescriptionsfor sipfeeds. / Informationenteredonto
PharmOutcomes about patient’s ongoingneedfor sipfeed,details of usage andwhenpatientlast assessedforneed.
Todisposeofunwantedmedicines
andreduce therisks associatedwith keeping outofdateandmedicines nolonger prescribed / Informationenteredonto
PharmOutcomesfromdisposal formsandRIOscoring
Toproducemeasurable outcomes
onthelikelyreductionsin
emergencyadmissionsas aresult of theinterventionsmade / RIOscoring
Toinform futuredevelopmentsin
pharmaceuticalservicestothe houseboundpopulation. / Evaluation oftheproject

Theoutcomesof thisserviceto be evaluated October 2017

Appendix 1

Domiciliary MUR Pre-Flight checklist

Visit Schedule

/ Confirm appointments made – alterations noted
Leave copy of visit schedule for pharmacy team
Take visit schedule - make sure you have all postcodes & phone No’s
Check have ID: NHS Smart card/ personal company name badge etc

Paperwork to Go

/ Consent forms
Prepared MUR sheets with patient history on
GP feedback forms
Notepad

For the journey

/ A to Z Map and Sat Nav (not everywhere on sat navs)
Mobile Phone (and hands free kit)
Money for parking charges
“Pharmacist visiting” parking permit if appropriate

Equipment to take with you

/ Incheck device + tubes + clinical waste bag
DOOP bucket
Clipboard & Pen
Wallets to store completed forms in (to maintain confidentiality)
Confidential waste bag

Other handy stuff

/ Healthy Lifestyle leaflets (diet, weight management, alcohol) smoking)
How to use inhaler cards
What is a hypo? – leaflet
Pharmacy contact details for patient

Thanks to Gordon Heeley, Nottinghamshire LPC for sharing this useful aide memoire which you may find useful