The Medacy ‘3 i’s’  Structured Medication Review Model

The Medacy ‘3 i’s’ Medication Review Model is inspired by NICE guidelines (NG5) on medicines optimisation and the NO TEARS Tool. It is an approach which supports the aims of NG5 and the structure of the NO TEARS tool with practical elements and is designed for applied in the General Practice setting.

Aim

To ensure that both patients and the NHS derive maximum benefit from the investment in medication. It promotes a patient-centric model for reviewing medication that takes into account hard and soft measures that will optimise benefits from medication.  

Guiding Principle

The Medication Review is a patient-centred process aimed at supporting patients to get the most from their medication.  It’s an opportunity to ensure that a patient’s treatment is safe, appropriate and follows current guidance. The review involves three stages and needs to be based on up to date information. 

We must remember that for the vast majority of time, patients are under their own care or the care of family members or carers. The medication review is an ideal opportunity to educate patients and their families so that their self care is as effective as possible. The graphic below illustrates the proportion of time one particular patients spends in healthcare settings each year and how much time she cares for herself.

http://www.riggare.se/

The Medacy ‘3 i’s’ model for medication reviews

• Information gathering
• Interpretation
• Informed decision making

1. Information gathering

The first stage of the medication review process is about  gathering information. The information gathering includes both hard facts e.g. blood test results and clinical documents but also softer facts around the patients attitude towards their medication and the the reality of how they use their medication. This ‘soft’ information will be gathered during interaction with the patient and/or after a review of the patients notes.

This information gathering  stage will most commonly be completed by a practice nurse and HCA and forms the foundation for the rest of the med review process.

The default should be an annual review of medication completed during the month of the patient’s birthday

When to consider shorter time frames.

1. DMARDS – Re-authorise to cover time to next blood test
2. Deranged blood results – re-authorise until re-test.
3. CKD – stages 3a and 3b every 6 months. Stages  4 and 5 every 3 months.
4. Diabetics with HbA1c >58. Every 6 months.

These will be tagged as Major Issues

Hard Measures – 

1.Blood tests but which blood tests are required?

Follow the guidance provided by NECS.

 https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

2. Changings in care setting

Has the patient care setting changed since the last review? If it has, was a detailed medicines reconciliation process completed.

3. Have there been any medication related adverse effects since the last review?
4. Does the days between issues fit expectations?

5 .Does the patient take and medication they buy over the counter including vitamins and minerals? HCA

Softer measures 

Questions to be asked during initial blood appointment to understand the patients ideas, concerns and expectations and the reality of how they take their medication (ICE-R)

1. Does the patient have any concerns about the medication they take? HCA
2. Does the patients have any side effects
3. Does the patient know what they are taking their medication for?
4. Is there anything  we can do to imprpove compliance?
5. Would they like an appointment with practice pharmacist to discuss their medication?
6. Does the patient always take medications as prescribed? HCA

The person carrying out the initial blood tests is responsible for gathering this softer information via the Medication Review Soft Measures template

2. Interpretation

The interpretation of both the hard and soft data will be carried out by the a clinician and this role is ideally completed by a Clinical Pharmacist who was not involved with the initial diagnosis.

Hard Measures

Questions to consider:

1. Have there been any newly diagnosed conditions since the last review?
2. Are the patients blood results in line with expectation?
3. Are there any trends in the blood results?
4. Does the medication prescribed follow current guidelines?
5. Have the blood tests been carried out in line with expectations?
6. Are there any relevant clinical letters to consider?

Soft Measures

1. Is the patient taking any medications they no longer need?
2. Is there any inappropriate polypharmacy? Can we reduce medicines burden?
3. Could any of the prescribed medication be causing the reported side effects?
4. Is there any opportunity to decrease risks to the patient?
5. Are the prescribed medications having the desired effect for the patient?
6. Does the medication history indicate the patient is compliant?

7. Informed Decision Making

Once the information gathered has been examined informed decisions may be considered regarding a patient’s medication regimen. Any proposed changes should agreed with the patient, or if the patient does not have capacity, with their carer or guardian.  A note should be made in the patient’s record about the change and the reasons behind the change.

What do do if patients don’t come in for review?

We understand that patients lead busy lives and can find it tricky to come to practice for reviews. However, clinical safety is our priority so under no circumstances should you authorise medication when a review is more than one month overdue i.e. on a -1.

If a patients is on a -1 or more do not re-issue the medication and send a task to The Clinical Pharmacist  who will contact the patient to discuss. If the clinical pharmacist is on holiday, send a task to the patients GP

If a patient does not attend within the month of their birthday then those medications on repeat templates should be authorised for one month only.

Appendix 1 – Timeframe

Time                               Action

Month of birthday -2     Letter 1 sent to patients. Book in for review on month of birthday (Month -1 to +1 acceptable)

Month of birthday -1      Reminder letter sent

Birthday month             Information gathering

                                           Blood test completed – send task to CP and Soft measures template completed by PN or HCA

Birthday Month              Interpretation  –  Clinical Pharmacist to review hard and soft information. 

                                         Informed decision  – Clinical Pharmacist to agree any required changes to medication regimen as per practice policies. The patient should be informed of the decision to                                                                                          make any changes and given an opportunity to challenge the decision. All decisions to make changes must be patient-centred and based on best                                                                                                practice evidence.

For more information please call 07971 187921,  complete a contact form or email shaun@medacy.co.uk