Introduction Older people are frequently on complicated medication regimes and can have difficulty managing their medicines. Many are housebound and have no contact with a pharmacist. The NSF for Older People highlighted that up to 50% of older people may not be taking their medicine as intended and 5 to 17% of hospital admissions may be due to adverse drug reactions or interactions (1).

Method The aim was to provide a pharmaceutical care domiciliary visiting service, by trained community pharmacists to people (of all ages and illnesses) having problems taking or managing their medication. Twenty community pharmacists completed extensive training, including an MSc module (150 hours) on the pharmaceutical care for older people. Referral forms are received from any health professional, hospital or community based, and social services. The assessing pharmacist receives details of medication, relevant test results, allergies and major medical history from the patient's GP.

A domiciliary visit is made, including the carer or referrer if appropriate. It includes a full medication review (including over the counter medicines), an assessment of the patient's needs and a discussion concerning the medicines based upon the principles of concordance, in order to develop a tailored care plan. Clinical interventions are suggested to the prescriber and compliance issues are addressed.

Results ( interim analysis) The servicehad 600 referrals in the first year. The number of medicines ranged from 2 to 19 on referral and 2 to 15 after assessment. 23% of patients had their number of medicines reduced and 18% of patients had doses or frequencies of medication changed. 2.5% of patients had their medicines increased (e.g. aspirin and statins for CHD). Compliance aids (MDS) were arranged for 69% of patients and hoarded medicines were removed from 23% of patients.

Safety issues with medication discovered by the pharmacists, included delirium due to unnecessary prescribing and administration of oxybutynin, frequent hypoglycaemic attacks due to a high dose of glibenclamide, haphazard administration of digoxin and a patient having falls due to a benzodiazepine

Evaluation forms are sent to all referrers, 4 months after the pharmacist's visit. To date, 130 forms have been returned (response rate 77%). It has benefited 95% of patients/carers and 87% of patients were not having problems taking their medication. 73% patients/carers were better at remembering to take their medicines and stock levels of medicines were better controlled in 78% of cases.
"This patient previously had very poor compliance. She is now almost fully compliant and this has prevented frequent re-admissions which occurred previously." – comment received from GP

A preliminary analysis of 116 patients has shown that for 49 (42.2%) patients, 478 visits (mainly by district nurses) have been saved, over a 3-month period - estimating to have saved £23,360 over one year. Extrapolation for 600 patients would give a potential annual saving of £121,000, offsetting costs

Conclusions This busy service is highly valued and appreciated by professionals, involving a group of very highly trained community pharmacists. It supports the NSF for Older People, assists with targets for medication reviews and all five PCTs have now provided funding for a permanent service.

References
(1) Department of Health. 'Medicines and Older People'. Implementing medicines related aspects of the National Service Framework for Older People, March 2001.