ARTÍCULO DE OPINIÓN

 

Reflection on the pharmaceutical service in nursing homes; understanding reality to cover needs

Reflexión sobre la prestación farmacéutica en centros sociosanitarios; entendiendo la realidad para cubrir las necesidades

 

 

Juan F. Peris-Martí¹, Elia Fernández-Villalba¹, Patricia Bravo-José², Carmen Sáez-Lleó² and María García-Mina Freire³

¹Servicio de Farmacia RPMD La Cañada, Valencia.
²Servicio de Farmacia RPMD Burriana, Castellón.
³Servicio de Farmacia Residencia La Vaguada, Pamplona. Spain.

Correspondence

 

 

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ABSTRACT

The increasing concern regarding chronic care, which is a consequence of the current demographic progression, and the need to decrease the costs associated with its care, places a focus on social care homes caring for highly dependent patients. Simultaneously, the residential facilities are progressing in order to care for fragile patients with increasingly complexity, even though, with some exceptions, it is in parallel with the healthcare system.
Within this reality, pharmaceutical care is developing very differently in all the autonomic regions, and has become a reason for controversy. In this sense, diverse factors related with the patient care setting, but also linked to different pharmaceutical levels, make it difficult to implement a patient care model.
Faced with this scenario, it seems reasonable to analyze the situation from the perspective of the healthcare requirements of the institutionalized persons in these facilities, and in terms of the patient care that we can and should provide; subsequently, and based on this, we should be able to propose the basic guidelines for developing an efficient model of pharmaceutical care integrated within this patient care setting.

Key words: Nursing homes; Residential facilities; Frail elderly; Pharmaceutical care.

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RESUMEN

La creciente preocupación por la atención a la cronicidad, consecuencia de la progresión demográfica actual, y la necesidad de disminuir los costes asociados a su cuidado, sitúa uno de sus focos en los centros de asistencia social que atienden a personas de alta dependencia. A su vez, el ámbito sociosanitario está evolucionando para atender a un paciente frágil cada vez más complejo aunque, salvo excepciones, lo hace de forma paralela al sistema de salud.
Dentro de esta realidad, la prestación farmacéutica se está desarrollando de forma muy heterogénea entre las comunidades autónomas y es motivo de controversia. En este sentido, diversos factores relacionados con el ámbito asistencial, pero también con los distintos estamentos farmacéuticos, dificultan el establecimiento de un modelo asistencial.
Ante esta situación, parece razonable realizar un análisis de la situación desde la perspectiva de las necesidades sanitarias de las personas institucionalizadas en estos centros y de la atención que podemos y debemos prestar para, posteriormente, ser capaces de proponer las líneas básicas sobre las que desarrollar un modelo de atención farmacéutica eficiente e integrado para este ámbito asistencial.

Palabras clave: Centro de asistencia social; Anciano frágil; Atención farmacéutica.

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Introduction

The demographic progression and economic situation are forcing the most developed countries to direct their health systems towards chronic patient care¹; the epidemiological pattern has changed, and currently 80% of Primary Care visits, 60% of hospital admissions, and 70% of healthcare expenses are associated with chronic conditions².

As a consequence of this reality, the Strategy for Addressing Chronicity in the National Health System³ was published in 2012; this document established three key points: patient care by multidisciplinary teams with professionals from the healthcare and social services involved, guarantee of continuity of care, and maximization of the involvement by patients and those around them.

In recent years, public authorities have become increasingly interested in the population institutionalized in nursing homes(NH), in terms of pharmaceutical provision; this is particularly due to the need to reduce the costs associated with the use of medications. In this setting, Royal Decree 16/2012⁴ establishes in its Article 6 the basis for pharmaceutical planning in order to develop a specialized pharmaceutical care: to establish a specific pharmacy department, or a medication storage associated with a public hospitalpharmacy department of a public hospital. Private centres with less than 100 beds will also have the possibility to link the storage to a community pharmacy.

Pharmaceutical reality is complex, and its action in this setting is subject to multiple factors difficult to put together. There are pharmacy-related factors, such as the organization of this sector into different pharmaceutical services (hospital , primary and community care); and other non-pharmacy-related factors, such as the geographical dispersion of nursing homes, and the varied distribution among the different healthcare areas. The complexity of this scenario can explain, though only partially, the slow reaction by the different spanish autonomic regions to the new legal regulations and, at the same time, the publication of many articles and opinions in the specialized press regarding which pharmaceutical area should provide this patient care.

This article is intended to reflect on some basic issues which have not been well clarified, to destroy some preconceptions about the patient care setting, and to identify the needs of institutionalized persons, for the sole aim of collaborating in order to improve the care provided and, therefore, the health outcomes in the patients managed.

 

A brief analysis of the real situation. Nursing homes and models for pharmaceutical care

It is difficult to conduct a brief analysis, due to the existing diversity between the residential facilities in the different autonomics regions, particularly among those depending on social services. However, it is possible to declare that, in the same way that services depending on healthcare structures, such as home hospitalization units, have had an important development in recent years, the social care facilities are in continuous evolution, and are currently managing a heterogeneous population with increasingly complex health issues who require multiple levels of care in many cases, halfway between the hospital and their home^5,6. And all this, to a high extent, is conducted in parallel with the healthcare system.

From the perspective of Pharmacy, the situation is similar. The variety of pharmaceutical care experiences that we can find in Spain, both from the community pharmacy and from hospital pharmacy departments, is so important that its analysis would require an entire article. This situation led to the publication in 2013 of the report titled "Hospital Pharmaceutical Care in Nursing Homes. Analysis of the Situation and CRONOS-SEFH Proposal", prepared by the CRONOS work team of the Spanish Society of Hospital Pharmacy⁷, where the current situation is analyzed, and a proposal is made to be conducted from pharmacy departments.

There is a baseline problem: the use of non-care criteria (ownership of the centre and/or number of beds) results in a distribution between pharmaceutical servicess that makes it difficult to develop a real patient care model, which would be the key for developing activities and policies targeted to a rational use of medications and healthcare products and, ultimately, a better quality of patient care.

The objective must be to adapt the care model to the needs of this population and their healthcare setting. We analyze the current situation by reflecting on certain topics and scenarios frequently used in the discussion about which pharmaceutical services are required in this setting, and who must provide them.

 

Are institutionalized patients considered outpatients?

The nursing home is the place of residence of the patient. When a patient is admitted to a social care centre, the social worker will register him/her in the place where the centre is located. Therefore, the patient will be assigned to a general practitioner in the public health centre of this area.

This assignment does not indicate outpatient nature at all. Any person will have it by the mere fact of registration, regardless of being hospitalized, institutionalized, or living at home. A patient is considered an outpatient when is attended in the health centre and then return home. Drawing a parallel with this, it will be considered home care when patient care takes place in their home, while patients will be considered hospitalized or institutionalized when they stay in a centre in order to be managed there and by its staff, as occurs in the hospital setting and also in a nursing home.

This institutionalized patient profile is not clear from current regulations; however, the more recent rules go along this line, without specifying it directly. This appears in the previously mentioned RD 16/2012⁴, article 6, which places the social care centre at the same level as the prison system and the hospital setting, in terms of pharmaceutical regulation.

But the reality must be accepted, if an improvement in patient care is the objective; and, if necessary, regulations must be modified and the healthcare structure must be adapted. And the reality is this: patients in a nursing home are not managed by health centre but by a multidisciplinary team in the nursing home which, in the majority of cases, is not integrated within the health system.

 

Institutionalized patients require complex care, also from the pharmacotherapeutical point of view

Three situations which have a direct impact on medication management can be highlighted: age-associated pharmacokinetic/dynamic changes⁸, the prescription cascade⁹, and drug-drug and drug-disease interactions¹⁰. This complexity is responsible for the high incidence of hospital admissions caused by medication: between 3 and 5% of total hospital admissions (5-10% in terms of cost) in western countries^11,12.

Patients with multiple morbidities and functional and/ or cognitive deterioration will require a therapeutical approach centred in the person and not in each of the health issues separately. For this reason, the application of current clinical guidelines presents many limitations. It is not possible to extrapolate their indications to complex chronic patients, because the potential associated morbidities are not taken into account. Their objectives are usually focused on clinical benefit, and those aspects associated with safety are assessed with lower accuracy. Except for some cases, these guidelines don't include treatment recommendations for patients with limited life expectancy, and mortality reduction outcomes are prioritized over quality of life. And the functional and/ or cognitive deterioration of patients is not taken into account¹³. That is to say, complexity is not taken into account by guidelines recommendations.

This complexity entails, as well as multiple morbidity and frailty, a level of functional and/or cognitive deterioration (dependence) leading to complementary health and social care requirements for these patients.

The next question would be: Which is the level of complexity of those patients managed in these centres? Using data from different studies in nursing homes linked to Pharmacy Department La Cañada Nursing Home, we can state that almost 60% of residents present moderate to total dependence (I. Barthel<60), almost 50% present severe cognitive deterioration (MEC-Lobo < 14), there is a 28% prevalence of malnutrition or high risk of malnutrition, practically half of patients are at medium-high risk of pressure sores (Norton<12), and >60% would be considered pluripathological patients according to the classification by the Andalusian Regional Government's Ministry of Health and, therefore, according to the characteristics of this tool, at high risk of requiring hospital admissions.

 

Institutionalized patients are highly polymedicated

This is a widely used phrase, and it is true. Polymedication should not always be understood as poor clinical practice. Institutionalized patients present a major number of comorbidities which will often require using a high number of medications. The problem lies in their unnecessary or inappropriate use.

At the same time, this could be considered a health issue. The use of medications is the main intervention by the health system and, regardless of this, it is estimated that >50% of them are not adequately taken¹⁴. The percentage of patients taking 10 or more medications has increased from 1.9% in 1995 to 5.8% in 2010¹⁵, and it is obvious that the risk of problems associated with medication will increase with the number of medications taken. Causes are varied, and have an impact both on the patient/caregiver and on the health system ¹⁶.

In this sense, dispensing by a Hospital Pharmacy Department has been significantly associated with a lower number of medications per patient in public nursing homes for the elderly in Belgium¹⁷ and also in Spain.

For example, a retrospective study on the activity during the past two years of a hospital pharmasyst in the setting of comprehensive geriatric assessment in a nursing home with 108 beds allowed to reduce the percentage of polymedicated patients (from 79.3% to 64.6%) and to discontinue 262 medications (2.26 medications/patient); the most frequent drugs were hypnotic-anxiolytics, antipsychotics, anti-ulcer agents, and antidepressants.

This experience goes in line with what Maher et al¹⁸ have stated in an opinion article about the clinical consequences of polypharmacy: that the best intervention on this situation would be a multidisciplinary approach by a team including one clinical pharmacist.

 

Institutionalized patients present a higher risk of suffering drug-related problems

Institutionalized patients present a higher risk of suffering drug-related adverse events than outpatients ^19,20. This situation is due to multiple factors, depending on patients, their treatment, and the health/social system.

Polypharmacy increases the risk of presenting drug-related reactions from 13% to 82%, when going from 2 to 7 or more drugs as the defining criteria. The drugs most frequently associated with this are: cardiovascular agents, diuretics, anticoagulants, NSAIDs, antibiotics and hypoglycemic drugs²¹. The prevalence of polypharmacy (> 5 medications) in institutionalized elderly patients in Europe has been estimated in 75%, and there is a 24.3% rate of excessive polypharmacy (> 10 medications)²². This is caused not only by the duplicity in medical units and the number of prescribing professionals involved in patient treatment, but also by the number of pharmacies involved in dispensing, and the type of pharmacy service ¹⁶.

For example: When a predefined alert system, or trigger tool, was implemented in a nursing home with 96 patients, with a median of 6 medications per patient (range: 2-16), 130 positive alerts were detected, and 72.4% of patients presented at least one. The most frequent were constipation and falls, in 21.9% and 18.3% of patients, respectively. The medications more frequently associated with the alerts were: benzodiazepines, antipsychotics, and oral antidiabetics.

 

Pharmaceutical care based on the use of prescribing quality endpoints (STOPP/START)

In recent years, there has been a significant increase in the level of concern regarding the availability of procedures to assist healthcare professionals in the adaptation of treatment for polymedicated elderly patients. In this sense, probably due to their easy implementation and their better adaptation to the drug therapy used in Europe, there are multiple publications using the STOPP/START criteria²³ in order to analyze the quality of prescription in nursing homes and other patient care settings^24-26.

These criteria have not been created as a replacement for the comprehensive assessment of patients; in fact, they have not been designed in order to detect absolutely all potentially inadequate prescriptions, but the most preventable situations in daily practice; this circumstance allows them to be used in primary care as well as in the hospital or residential facilities settings.

In an initial assessment of the utility of these criteria, 41 patients from the nursig home RPMD La Cañada were included ramdomly, with 83-years-of-age (SD: 3.9), a medium level of moderate functional dependence, and moderately severe cognitive deterioration. The findings were 33 STOPP criteria and 23 START criteria. After multidisciplinary assessment (by the physician, the pharmacist and the nurse), 60.6% of STOPP criteria were applied, and none of the START criteria. The causes for the lack of implementation of these criteria were: patient stability (n=10), limited life expectancy (n=10) and treatment directed by specialized care (n=3).

Given this situation, the solution is not a systematic implementation of these or other criteria, but a multidisciplinary approach that includes the need for a periodical review of medication, and takes into account the benefits of deprescribing²⁷. Along this line, we understand the integration of the pharmacist within a nursing home, because this action becomes more relevant when polymedication is combined with frailty²⁷, in order to achieve the adaptation of treatment to the evolution, prognosis, preferences and quality of life of patients.

 

Antipsychotics are excessively used in the sociosanitary setting

Another widespread claim, and also true. There have been many publications in recent years about the excessive use of antipsychotic medications in elderly patients with dementia in nursing homes. This situation has led to many centres, companies, and organizations such as CEOMA (Spanish Confederation of Organizations for the Elderly) to lead a critical school of thought regarding this, and to promote the development of programs targeted at a more rational use of these medications, prioritizing non-pharmacological measures, and untying patients as much as possible²⁸. This is not the real situation in all centres, but there have been advances in this respect in many of them; and it must be said that this has been achieved without any support by the healthcare structure.

However, there are few articles highlighting another reality: the majority of these patients are already on excessive antipsychotic medication at the time of admission in the nursing home. This is a clear example of the way in which the patient care setting will also determine treatment: the home/outpatient setting is different to the institutionalized patient setting. A patient with dementia and behavioural alterations in his family setting can require a different treatment for many reasons, such as an excessive workload for the caregiver, or lack of carer; on the other hand, a residential facility will have a clinical team with the ability to manage this type of patients and situations, with non-pharmacological and pharmacological measures.

In a multidisciplinary program initiated in 2012 about the adaptation of antipsychotic drugs in patients with dementia in a nursing home with 120 beds, 35 patients were included (mean age: 82.3 years; SD: 5.8) according to predefined selection criteria. After the individual assessment and sequential discontinuation of these medications, the outcomes were: total discontinuation in 28 patients (80%) and dose reduction in 7 patients (20%). It must be highlighted that it was only necessary to re-initiate antipsychotic treatment in two patients whose medication had been discontinued, and in both cases at a lower dose (data from the Pharmacy Departmentof Burriana Nursing Home).

 

Institutionalized patients present a high risk of malnutrition

Elderly patients present a higher risk of malnutrition than other age groups. The risk and occurrence of malnutrition in this group is caused by physiological risk factors (lower energy expenditure), physical and clinical factors (chewing and/or swallowing problems, chronic diseases, medication, etc.), and psychosocial factors (cognitive deterioration, depression). The Predyces study indicates that 23% of patients hospitalized in our country are at risk of malnutrition, and those >70-year-old present the higher risk (37%)²⁹. There was a 50% prevalence of malnutrition in >75-year-old patients at hospital discharge²⁹. In the same line, different studies state that the proportion of malnutrition in institutionalized elderly patients ranges between 18 and 38.6%³⁰.

A study conducted in 2008 with 1,148 patients institutionalized in 16 nursing homesof Valencia region showed a malnutrition prevalence of 11.5%, with 16% of patients at risk, and a high prevalence (25%) of obesity³¹.

Malnutrition in institutionalized patients is a key factor in the development of frailty. For this reason, institutionalized patient care demands interventions in order to prevent risks and improve the nutritional status, to a higher extent than in other settings. In this sense, the implementation of a multidisciplinary protocol for nutritional screening and assessment adapted to this population will allow to conduct a follow-up in this type of patients, and interventions for those who require it.

The presence of polymedication can also have a negative impact on the nutritional status of patients³³. The risk of losing weight is three times higher in those patients taking 5 or more medications vs. those who take fewer drugs³⁴. Moreover, the use of antidepressants and/or antipsychotics can have a significant impact on patient's appetite and weight, and this circumstance must be taken into account when adapting treatment to each patient and clinical situation.

Nutritional care is complex and also requires a multidisciplinary approach; the team must include healthcare professionals (physician, pharmacist, nurse) and dieticians, able to offer the individualized care required by each patient³³.

In line with everything stated so far, a pharmacy department targeted to this type of patients should have access to the most adequate nutritional resources (specific for feeding tubes, oral supplements, adapted texture, etc.) and be able to work together with the rest of the team in terms of patient assessment, for an adequate nutritional and pharmacological treatment.

 

Nursing homes have developed a patient care system parallel to the NHS. How far should this go?

So far, patient complexity and care have been assessed. But, how far should we go in terms of patient treatment in the nursing homes? This is the question. It seems reasonable to think that the level of patient care to be conducted should be determined by the public health system, probably after an assessment of what is more convenient or beneficial for the patient; of course, without forgetting efficiency for the health system. However, this does not happen.

Nursing homes have developed over time a model of multidisciplinary care for institutionalized persons. In fact, this is demanded by current regulations; and there is a team in the majority of these centres, formed at least by the centre management, a clinician, nursing staff, a psychologist, a physiotherapist, a social worker, and a sociocultural entertainment technician; this team will manage patients from a multidimensional perspective, and will try to cover their healthcare and social needs.

In the majority of centres of the diferents spanish regions, this patient care is conducted in parallel with the National Health System. The Strategy for Addressing Chronicity ³ has acknowledged this, and stated the need to work for an organizational and structural integration able to manage complex chronic patients in the most adequate way possible.

Here we find a critical / troublesome point: On a structural level, the healthcare provided to patients in nursing homes is not integrated and does not have a simple coordination with the healthcare system; and, on the other hand, patients are increasingly complex, with higher frailty and more requirements regarding healthcare. Therefore, it is recommended to avoid the transition between healthcare levels, and to achieve an effective communication with hospital clinician in order to manage situations that can be addressed from the centre³⁵.

The morbidity associated with Alzheimer's Disease, the implementation of palliative care, or the clinical complexity of many of the persons managed, are situations that cannot be left outside the health system, if the objective is to offer the best patient care available.

Speaking in specific clinical terms, as an example, pneumonia acquired in a nursing home should be considered as hospital-acquired pneumonia (and not community-acquired pneumonia), because the prevalence of multi-resistant pathogens is similar to the hospital and, therefore, the need for broad-spectrum hospital use antibiotics will also be similar³⁶.

In line with the previous example, those nursing homes linked with a hospital pharmacy department have access to treatment with hospital use medication, which will be beneficial for patients by avoiding the risks of hospitalization and transition between patient care levels, and will also offer an economic benefit to the public health system by preventing a hospital admission, which is one of the main objectives of the plan for chronic patient care. But the hospital pharmacy is not enough to address this possibility; an integration of resources will be essential.

It is true that steps are being taken in order to improve continuity of care. Some regions have an electronic clinic history which is shared by the different care levels, including the residential facilities setting; others have incorporated the health systems professionals. These are positive initiatives, but still isolated, and often targeted to control the prescription of medications. To incorporate tools or to coordinate certain patient cares could encourage an improvement; but this will be insufficient if structures have not been previously integrated, that is to say, if no clinical integration between teams and professionals has been ensured³⁷.

 

Acute Care Hospitals cannot manage institutionalized patients in a convenient manner

Nursing homestaff will usually complain about the conditions in which patients return after hospital discharge. Hospital stays will usually cause health issues in fragile patients: pressure ulcers, disorientation, confusion or weight loss. This situation will lead to an increase of their vulnerability, which will be sustained during some time after hospital discharge; some authors have called it "post-hospital syndrome"³⁸. In this sense, data collected in 2014 from 12 nursing homes (n=920) linked to the Pharmacy Department La Cañada Nursing Home show that a fourth of all pressure ulcers have an external source (hospital, home) when the number of hospital stays is much lower.

This reality demands a reflection about how and where these persons should be managed, making the most of the different resources, in order to ensure an adequate care and location at all times. Two points that must be worked upon could be determined: a) Improving the care received by these people in hospital, offering a more patient-centred care, and not focusing all efforts exclusively on the problem leading to their admission³⁷, and b) Encouraging patient care within their centre, avoiding hospitalizations that are not beneficial for the patient.

 

MDS as a basic tool for pharmaceutical care in sociosanitary centres

The use of monitores dosage systems (MDS) has been widely proposed, and even incorporated in some regulations and/or programs for action, as a basic tool for pharmaceutical care in the setting of social care centres. But are we sure that this is the most adequate system? In this setting, as well as in the hospital setting, this will mean not only dispensing, but also administering the medication and conducting patient follow-up.

The NHS England does not consider that its use would be adequate in this type of centres, because they understand that its contribution to safety is not completely clear, and their use does not seem to reduce the number of medication errors, when centres using these systems are compared vs. centres that do not use them^39,40. On the other hand, they do find an advantage in terms of scale economy, by making easier the preparation of medication in a centralized way³⁹.

In our experience, medication dispensing must be conducted according to a system of individualized single doses, adapted to the clinical setting, that will maximize safety and, at the same time, facilitate nursing work for an adequate administration of medications. In this clinical setting, where institutionalized patients are managed by a healthcare team, the same as in hospitals, the Pharmacy Department does not dispense the medication directly to patients, but prepare it for administration by the nursing staff. And this must be done under the best conditions, that is to say: individualized by patient, correctly identified, and within a system that will make nursing work easier and minimize errors.

 

From reflection to proposal

Treatment approach for complex chronic patients is difficult, both for the healthcare professional managing them and for the professional who must prepare a plan of care from different social and healthcare resources that must be interconnected.

It could be claimed that any model of care proposed should be sustainable, provide some value, adapt care to the situation of each patient and their empowerment; and therefore it should be multidisciplinary, with the objective of obtaining a synergy with the actions of each professionals, and achieving a better outcome than the sum of each one separately³⁷.

Based on these premises, and on the experience of Hospital Pharmacy in this setting of care, we understand that the model of pharmaceutical care in nursing homesmanaging complex patients should meet the following characteristics:

- It must be integrated within the Health System, being part of the healthcare structure. In fact, the whole healthcare offered to patients institutionalized in nursing homes should be integrated within the Health System.

- It must be able to adapt to the setting of care. Follow-up for complex chronic patients requires collaboration with different healthcare and social professionals, in an area with few certainties at pharmacotherapeutical assessment.

- It will be linked to the pharmacy departmentsof the hospital of reference, or implemented in the nursing home in order to have a higher ease of adaptation, according to the reality in each area / healthcare area, and based on the number of centres and patients to be managed.

- Regardless of the structure created, the pharmacist must be able to conduct his patient care work in the nursing home. It is worth insisting in the fact that the best outcomes are obtained when acting at a micro level, that is to say, with the healthcare professional as a member of the healthcare team⁴¹. Only this way it will be possible to provide a value that will have impact on the health status and/or quality of life of the patient managed.

The reflections in the present article are intended to expose the need to place patients in the central axis of the assessment about which level of pharmaceutical care should be conducted in this clinical setting. The type of patient care cannot be the result of a simple analysis of direct costs or vested interests; it should be derived of a somewhat more complex analysis. Developing a system for distribution in single doses adapted to the setting, incorporating a formulary system from a pharmacy and therapeutics comitee, adapting pharmacological treatment to the real situation of the patient based on a comprehensive geriatric assessment, or collaborating in the improvement of the patient care ability of the centre in order to prevent transitions in care and to reduce avoidable hospitalizations, are real improvements offered from the Hospital Pharmacy that will provide a clinical value and, at the same time, will favour the sustainability of the system.

However, this is not enough. The proposal, in four brief items, insists on the need to work in an environment of clinical and not only pharmaceutical integration, as the only possible way to address with security an improvement in the healthcare for these patients, and to guarantee continuity of care.

 

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Correspondence:
Correo electrónico: peris_jua@gva.es
(Juan F. Peris Martí).

Recibido el 22 de diciembre de 2015;
Aceptado el 27 de marzo de 2016.