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Quality Improvement and Medication Safety In Long Term Care Keith A. Swanson, Pharm.D., CGP University of Oklahoma College of Pharmacy Learning Objectives Upon completion of this presentation participants will be able to: Identify types of medications associated with medication misadventures in frail elders List one factor or behavior for each of the following groups of individuals that increases risk of inappropriate medication use in elders: physicians/prescribers nursing staff family/caregivers residents Identify key points in the medication use process in post-acute and long term care systems that increase the prevalence of medication misadventures and identify directions for corrective actions Issues in Geriatric Pharmacotherapy Elders are admitted to hospital three times the rate of younger people as a consequence of an ADR Elders experience a disproportionate number of deaths and hospital admissions due to adverse drug reactions 28% of hospital admissions through the emergency room by older people are due to poor outcomes from drug therapy (16% ADRs, 12% non-compliance) Most common drugs causing admission from ADRs Insulin, warfarin (anticoagulants), digoxin Did You Know… Estimated cost of inappropriate medications and their consequences in older people approaches $200 billion/year $32.8 billion associated with DRPs resulting in LTC admissions Estimated 50 to 75 thousand deaths annually amongst older people in US due to ADRs or non-compliance Estimated 25% of all prescribed medications for older people are inappropriately selected or dosed in older people Estimated 30% of all medications for older people are considered unnecessary Often referred to as: “America’s Other Drug Problem” Medication Misadventures in Post-Acute and Long Term Care Medication discrepancies during transitions in care Prescribing ‘cascades’ and unnecessary medications lead to polypharmacy Unintended negative outcomes Falls Cognition changes Hypoglycemia Excessive bleeding or thrombus formaton Anticholinergic effects (dry mouth, constipation, urinary retention, delirium) Cardiovascular effects (hypotension, dysrhythmias, thrombosis, sudden death) Failure to reach therapeutic ‘targets’ (e.g. untreated pain) Mapping Medications through a Recent Transition Send to ER: Change in Mental Status Current Discharge Medication List: Fall Discharge Orders: Fall “resume NH orders” ASA 81 mg Daily ASA 81 mg Daily ASA 81 mg Daily Divalproex 125 mg Daily Divalproex 125 mg TID Divalproex 125 mg Daily Donepezil 10 mg Daily Donepezil 10 mg Daily Levothyroxine 50 mcg Daily Levothyroxine 50 mcg Daily Levothyroxine 50 mcg Daily Lorazepam 0.5 mg BID Lorazepam 1 mg q6H PRN Lorazepam 0.5 mg BID Metoprolol 25 mg Daily Metoprolol 25 mg Daily Metoprolol 25 mg Daily Mesalamine 800mg TID Mesalamine 1200 mg BID Mesalamine 800mg TID Calcium+D 500/400 Daily Diphenhydramine 25mg HS Ibuprofen 800 mg q8H prn Quetiapine 50 mg BID OC (86 y/o M) sent from ALF to ER for change in mental status. Returned later same day. Mapping Medications through a Recent Transition Send to ER: Change in Mental Status Current Discharge Medication List: Fall Discharge Orders: Fall “resume NH orders” ASA 81 mg Daily ASA 81 mg Daily ASA 81 mg Daily Divalproex 125 mg Daily Divalproex 125 mg TID Divalproex 125 mg Daily Donepezil 10 mg Daily Donepezil 10 mg Daily Levothyroxine 50 mcg Daily Levothyroxine 50 mcg Daily Levothyroxine 50 mcg Daily Lorazepam 0.5 mg BID Lorazepam 1 mg q6H PRN Lorazepam 0.5 mg BID Metoprolol 25 mg Daily Metoprolol 25 mg Daily Metoprolol 25 mg Daily Mesalamine 800mg TID Mesalamine 1200 mg BID Mesalamine 800mg TID Calcium+D 500/400 Daily Diphenhydramine 25mg HS Ibuprofen 800 mg q8H prn Quetiapine 50 mg BID OC (86 y/o M) sent to ER from ALF for change in mental status. Returned later same day. Pharmacy Issues in Care Transitions Two-thirds of patients admitted have unintended medication discrepancies* Many are unresolved at discharge Potential harm with medication discrepancy ranges from 11 to 59% 40% to 80% of discrepancies considered ‘insignificant’ 13% Medicare readmission rate – most considered preventable Two-thirds believed medication related *Kwan et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med 2013;158:397-403 Potential Causes Medications not ‘available’ to patients after discharge “It’s quittin’ time” or “gettin’ ready for the weekend” discharges Short timelines create pressures on staff and put resident at risk Time delays after daily pharmacy deliveries Hard to find and high intensity or expensive therapies Insufficient staff at both ends of the call to answer questions or investigate inconsistencies Reliance on existing data that hasn’t been updated or reconciled against current therapies Potential Causes Medications not ‘necessary’ for patients Hospital ‘habits’ - stress ulcer prophylaxis, DVT prophylaxis, appetite stimulants, treatment for acute delirium Unnecessary PRNS - Antiemetics, analgesics, laxatives/antidiarrheals, hypnotics Inpatient formulary changes Consulting prescribers – specialty physicians, dentists, podiatrists, alternative health practitioners, family members Impact of polypharmacy at ‘step-down’ Risk of ADRs and non-adherence ‘Affordability’ to patients and post-acute care facilities Medication Issues Identified in a Recent Transition 70 Y/o male admitted to SNF following surgery to repair torn muscles and ligaments in leg Prior history of mechanical valve replacement on warfarin Prior dosing 10 mg daily with extra 5 mg one day a week (75mg weekly) ER med history incorrectly listed dose as 20 mg daily with an extra 5 mg dose (15mg total) one day a week (135 mg weekly) Discharge order was 5 mg daily (35mg weekly) with enoxaparin bridge until therapeutic INR (2.5 to 3.5) Also restarted previous antidepressant therapy that was discontinued 9 months prior to surgery due to adverse effects Medication Issues Identified in a Recent Transition Failure to reinitiate known pre-hospital anticoagulant dose incurred following ‘costs’ Required 2 full weeks to achieve therapeutic anticoagulation (enoxaparin stopped at day 4 & had to be restarted when issues discovered) Enoxaparin ‘bridge’ cost (approximately $10 per day) 6+ INR lab tests (approximately $20 per test) Quality of life and satisfaction Issues related to reinitiating the antidepressant Resident admitted his ‘current’ med list still included discontinued antidepressant Despite strong resistance from resident, hospital and post-acute care staff insisted the potentially harmful therapy was administered as ordered Lessons to be Learned How would staff at your facility handle this situation? What about the enoxaparin order ‘for 4 days or until warfarin therapeutic’? Would your staff have concern about this warfarin regimen? How would your staff treat someone who refuses to take an ordered medication? Would your staff step forward to investigate the situation? Patient Safety Strategies Medication Reconciliation “Formal process for identifying and correcting unintended medication discrepancies across transitions of care”* Widely endorsed and mandated *World Health Organization (2006) & Institute for Healthcare Improvement (2006) Patient Safety Strategies Best Possible Medication History (BPMH)* Cornerstone for medication reconciliation More comprehensive than routine medication history Requires two steps: Systematic process obtaining thorough history of ALL prescribed and nonprescribed medications (structured patient interview) Verification of information against at least one reliable source (database, vials, PMD or pharmacy records, etc.), *World Health Organization (2006) & Fernandes (2012) Patient Safety Strategies Advanced Medication Reconciliation Requires interprofessional collaboration Team Approach: Prescriber – Nurse – Pharmacist Must include patient/caregivers in discussions/decisions Requires integration into admission histories, progress notes & discharge summaries Requires effective patient education and medication counseling Integrated Components: Discharge care plan counseling Coordinating follow-up appointments Postdischarge telephone calls and contacts *Kwan et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med 2013;158:397-403 Patient Safety Strategies Potential Benefits of medication reconciliation Reduced risk of Preventable Adverse Drug Events (pADEs) and Adverse Drug Events (ADE or ADR) Reduced readmissions and emergency department visits at 30 days Reduced hospital visits at 12 months Potential Harm Mistakes are ‘hard-wired’ into patient record Practitioners rely on record and don’t confirm accuracy with patient or other sources Risk of process taking key personnel (pharmacists) away from other patient safety activities *Kwan et al. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med 2013;158:397-403 Patient Safety Strategies Factors affecting impact of medication reconciliation Degree to which patients (and the ‘system’) can provide current medication history Health literacy and language EMR, prescription databases Clinical informatics milieu Integrated medication reconciliation into computerized order entry, EMR Costs and available personnel Reconciliation of medication ‘list’ doesn’t guarantee appropriateness of care Patient Safety Strategies Medication Therapy Management Care provided by pharmacists with goal to optimize drug therapy and improve therapeutic outcomes Thorough medication therapy review with individualized action plan with follow-up and documentation of action Resources – Clinically focused pharmacist Process provides for timely review of all therapy Communication pathways to prescribers Systems for collecting, sharing, and documenting information and interventions Medication Therapy Management Return on Investment Health Partners MTM Cost Savings Analysis (prepublication data) 706 MTM patients - over 1.5 years $331 PMPM savings = $2.8M TCOC reduced 18%; ROI = 11:1 Clinical and Economic Outcomes of MTM Services: Minnesota Experience (BCBS Mn Analysis) (JAPhA 2008;48:203-11.) 285 MTM patients over 1 year (2007) TCOC reduced 31% ($3750 PMPY); ROI = 12:1 *PMPM = Per Member Per Month; TCOC = Total Cost of Care; ROI = Return on Investment Potential Solutions Post-discharge pharmacist medication reconciliation Decreased readmission rates at 7*, 14*, & 30 day Financial savings of $35,000 per 100 patient discharges 80% of discharged patients in this integrated group practice and health plan had at least medication discrepancy on discharge Kilcup M, et al. Post discharge pharmacist medication reconciliation: Impact on readmission rates and financial savings. J Am Pharm Assoc 2013;53:78-84. Potential Solutions Medication Reconciliation Toolkit (104 pages) Medication Reconciliation Toolkit Guiding Principles for Reconciliation Programs “Define Roles and “One Source of Truth” Responsibilities” “Standardize and “Make Simplify” the right thing to do the easiest thingPrompts to do” “Effective or Reminders” “Patients and “Laws or Regulatory Caregivers” “Link to other goals or Requirements” initiatives” Transitions - Pharmacy “Pearls” Advanced Medication Reconciliation is only one piece of an integrated plan CURRENT and ACCURATE information is key; Goal is ‘One Source of Truth’ Resources ($$$, time, personnel, technology) are required Patient health literacy and beliefs must be assessed and addressed Attention to detail and assuming ‘no one else noticed this’ Summary Transitions in care put patients at risk due to poor communication and inadvertent information loss Unintended medication discrepancies are common, but often with limited harm (acutely) Significant discrepancies have high risk and high cost to patients and systems Medication reconciliation is just one tool that can be implemented Medication reconciliation must be ‘teamed’ with early comprehensive therapeutic review An integrated approach is necessary to maximize benefit from decisions and interventions to reduce risk across the care continuum Exercise – Identify one specific issue you would like to address to optimize medication outcomes and transitions Create a vision – what would the top of the mountain look like Outline a plan – what would it take to get there Devise a process you’d like to see at your facility Develop a timeline – what would it take to get started Assuming adequate resources (not unlimited) Exercise Example Your facility has entered into an agreement with a local acute care hospital to provide post acute care for elders after elective hip and knee replacements A post-care survey indicates 18% of the residents surveyed indicate inadequate pain control on the first day of admission. Review of the current residents admitted reveals the following information: Number of residents arriving after 4 pm: 6/20 (30%) Number of residents arriving without ‘paperwork’ or ‘hard’ copies of prescriptions for controlled substances: 3/20 (15%) Number of residents ordered only PRN pain medicines: 7/20 (35%) Identify the Issue Create a Vision Outline a Plan Devise a Process Develop a Timeline Exercise Example 72 year old man with Type 2 Diabetes Mellitus and history of renal insufficiency Currently prescribed glyburide in addition to metformin Glyburide is considered potentially inappropriate in elderly (BEERs List) due to very long duration of action especially with renal insufficiency Metformin contraindicated with renal insufficiency FSBS values this week – 2 values below 70 mg/dL (requiring nursing intervention) with no values above 115 mg/dL Identify the Issue Create a Vision Outline a Plan Devise a Process Develop a Timeline Summary (repeated) Transitions in care put patients at risk due to poor communication and inadvertent information loss Unintended medication discrepancies are common, but often with limited harm (acutely) Significant discrepancies have high risk and high cost to patients and systems Medication reconciliation is just one tool that can be implemented Medication reconciliation must be ‘teamed’ with early comprehensive therapeutic review An integrated approach is necessary to maximize benefit from decisions and interventions to reduce risk across the care continuum QUESTIONS AND COMMENTS?