Rushcliffe Clinical Commissioning Group (CCG) has been working with Principia, one of the NHS Vanguard sites in England delivering Multi-Speciality Community Provider (MCP) services in Rushcliffe, to reduce unnecessary oral nutritional supplements (ONS) intake.
Between 57% and 75% of oral nutritional supplements are prescribed inappropriately, resulting in significant waste and avoidable costs, according to a London audit data from the London Procurement Partnership (LPP).
The problem
Rushcliffe Clinical Commissioning Group (CCG) has been working with Principia, one of the NHS Vanguard sites in England delivering Multi-Speciality Community Provider (MCP) services in Rushcliffe, to reduce unnecessary oral nutritional supplements (ONS) intake.
Between 57% and 75% of oral nutritional supplements are prescribed inappropriately, resulting in significant waste and avoidable costs, according to a London audit data from the London Procurement Partnership (LPP).
The problem
ONSs are a common treatment for malnutrition, which have proven to have clinical benefits.
But inappropriate prescribing can be costly. It can also mean that patients may not receive the best support, advice and information specific to their needs.
What we did
Started in July 2017, Principia MCP employed a prescribing support dietician to provide an enhanced service to GPs and care homes.
The role aims to support GP practices to review the use of oral nutritional supplements, by encouraging appropriate prescribing and ensuring patients are regularly reviewed.
It also provides training and guidance to care homes, including preventative work to provide better nutrition aimed at reducing frailty and providing early intervention to reduce risks of malnutrition.
To date, 17 care homes and seven practices have been involved.
Care homes have been supported with training in Malnutrition Universal Screening Tool (MUST) and Food First, as well as further training specific to their needs, such as diabetes.
Objectives
· Ensuring healthcare professionals are supported with guidelines on oral nutritional supplements and Area Prescribing Committee (APC) formulary and have easy to access advice from a dietitian
· Making dietetic advice available in primary care
· Promoting appropriate prescribing of oral nutritional supplements, regular review and treatment goals set for patients in the community
· Encouraging the use of cost effective products and powdered supplements as first line
· Increasing patient follow-up in the community to provide support and improve continuity of care and encourage better health at home
· Improving education for MUST risk screening and Food First within care homes
· Improving nutritional outcomes in residents within care homes
· Encouraging the use of the MUST Pathway to support early intervention and care for those identified at risk of malnutrition
Results
After three months, reviewing of oral nutritional supplements resulted in a significant reduction of inappropriate prescribing. It led to a discontinuation of 40% of oral nutrition prescriptions within the reviewed practices.
A further 30% of prescriptions have been changed to be more cost effective, nutritionally appropriate or gradually reduced.
Prescriptions are often continued without a clear aim of treatment or review – the average length of these being 17 months, with the longest found to be 20 years.
Care homes that received training saw an increase in accuracy and improvement of MUST scores of residents, despite reduction of prescribed supplements.
In one case, one care home showed an improved score accuracy from 51% to 91%.
Encouraging care homes to standardise and simplify their documentation of MUST scores and food record charts has meant that documentation is easier to understand, improving efficiency.
Many of the care homes are using over the counter supplements. Suggestions, such as switching to fortified homemade milkshakes, are a significant cost saving for them and reduce risks of inappropriate prescribing, including incorrect texture or complications with diabetes or patients with low estimated glomerular filtration (eGFR).
The future
The Prescribing Support Dietitian role is contracted for Rushcliffe CCG until March 2018.
We will work with all practices within the CCG to review prescriptions of oral nutritional supplements and continue to provide MUST and Food First training to care homes.
We will create specific dietary sheets for conditions to support patients in their own homes, as well as a F12 MUST and dietary advice quick search for GPs and health care professionals to signpost to for further information and guidance.
Utilising the OptimizeRx prescribing tool, which is already in place in Rushcliffe GP practices, will deliver cost effective prescribing of oral nutrition supplements in practices across Greater Nottingham.
CCG comment
‘Our vision is ‘to provide a better quality of care for the people of Rushcliffe through an innovative, patient-centred, coordinated care delivery system, which is designed to improve our communities’ health outcomes, increase our clinician and staff satisfaction, and at the same time, moderate the cost of delivering that care.’
Nicole Baconis the Principia MCP Development Manager and programme leadat Rushcliffe CCG
