2852 A proactive multidisciplinary approach to reviewing health and care needs of nursing home residents in a primary care network

Abstract

Introduction We proactively reviewed nursing home residents using a multidisciplinary team (MDT) approach within a Primary Care Network (PCN). We aimed to enhance care coordination, reduce inappropriate medication use and ensure all residents had current advanced care plans in place. Method An MDT comprising a geriatrician, prescribing pharmacist, general practitioner, and nurse reviewed residents proactively. This involved reviewing the residents’ current health and care needs, falls risk, medication regimens and advance care plans. We then performed medication reviews, reviewed advanced care plans, and identified the need for further interventions. When we repeated the process, we used a proforma that could be pre-populated prior to the meeting by the pharmacist and geriatrician to improve efficiency of the discussion. Results The initiative was piloted in two residential nursing homes with a total of 65 residents reviewed, of which 86% (n = 56) received interventions. There was a 47% (n = 29) increase in completed advanced care plans. 62% (n = 40) of residents had medicines optimised, with polypharmacy being reduced in 46% (n = 30) by an average of 2 medications per resident. 8% (n = 5) were referred to additional services and 8% (n = 5) required further investigations. Conclusion(s) This proactive MDT model effectively addressed the needs of residents whilst demonstrating immediate positive outcomes. Key facilitators to good practice were teamwork, clarifying the objectives of the MDT, prior reviews of patient records, and ensuring staff who knew the residents well were present. We will use this approach with other nursing homes within the PCN and share our results with colleagues. This has the potential to reduce costs of medications and hospital admissions, as well as improve quality.