Jigsaw 101: Meidcation Initiative in Action Polypharmacy in the Elderly


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Presented at Optimizing Medications workshop in Vancouver by Christine Gemeinhardt

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Jigsaw 101: Meidcation Initiative in Action Polypharmacy in the Elderly

  1. 1. KinVillage Polypharmacy Reduction Pilot Project “The Jumpstart” Christine Gemeinhardt, MD, MSc, CCFP Medical Coordinator January 16, 2014
  2. 2. Disclosure Statement No conflict of interest
  3. 3. Project Team • • • • • Christine Gemeinhardt, Medical Coordinator Edwin Lee, Pharmacist Kelly Marshall, RN, Clinical Practice Leader Cynthia Langenberg, Director of Health Services And all other participating care staff
  4. 4. Results January 2013 – June 2013 Time 0 6 months Total # meds/99 residents Total # meds/99 residents 897 Meds/resident 9.0 659 Meds/resident 6.7
  5. 5. Change in Meds Pilot Project 2.3 per resident 26%
  6. 6. Time to backtrack………. What made this project possible? (Nursing homes are heterogeneous) KinVillage demographics: Tsawwassen, S Delta Contracted site Fraser Health Authority 99 residents - 13 Special Care Unit
  7. 7. The Team Medical Director, RNs, LPNs Med Review Team Clinical Practice Leader Pharmacist
  8. 8. Project Medication Reviews Intensive Work: 33 residents/week 4-5 minutes/resident 2 ½ hours per session Weekly sessions X3 99 residents “Jumpstarting”
  9. 9. Pre-requisites for Rapid Fire Med Reviews!
  10. 10. “Jumpstart” Med Review Timeline Start 0 6 months 3 months
  11. 11. Process – Pharmacist Medication Count Time 0 January 2013 6 months June 2013 Post project follow up 12 months January 2014
  12. 12. Our Pharmacist, Our Hero
  13. 13. KinVillage Polypharmacy Reduction Pilot Project Frail residents are at the end of their life cycle “Medication focus” wastes valuable nursing time Basic premises Residents receive too much medication Focus on quality of life, not cure or longevity
  14. 14. Earlier initiatives that made KV ripe for a polypharmacy reduction project 2011 Hospital Transfer Reduction Project 2012 Education on the palliative paradigm Use of FH Protocol for the Actively Dying 2012 KV Physician Agreement Change in physician coverage demographics Unscheduled hospital transfers from 10% to 4% meds & transfers Number of different MRPs from 23 to 14, improved engagement Number of residents under Med Coordinator
  15. 15. Travel time, inconvenience, too few residents Lack of interest, other areas of commitment Aging and semiretirement Attrition of community physicians
  16. 16. Physician Agreement Unable to accept or meet requirements Attrition
  17. 17. Physician Agreement Accept Engaged
  18. 18. Kin Village Physic ian Agreement Dear Dr _______________________, Date: __________________ Your patient, _________________________________, Complex Residentia l Care. is now a resident Eac h resident at Kin Village has a Ma in Responsible Physic ian (MRP). fulfill the follow ing duties: of Kin Village - The MRP is asked to Be ava ilable to rec onc ile the resident’s medi ations the day of admission c Visit the resident w ithin 2 w eeks of admission Visit the resident routinely on a quarterly basis, review w ith nursing staff, and write leg ible c hart notes 4. Provide timely onsite assessment and c are w hen the status of the resident c hanges 5. Provide timely onsite assessment prior to initiating transfer to hospital and c ommunic ate w ith the Emergenc y Physic ian 6. Meet w ith the resident’s representative(s) in person to c omplete the MOST ( Fraser Health Medic al Orders for Scope of Treatment) w ithin a w eek of admission. 7. Meet w ith the resident’s representative(s) during the end-of-life phase 8. Attend the resident during the end-of-life phase 9. Attend annual or biannual multidisc iplinary c are c onferenc es. 10. Provide a replac ement MRP w hen unavailable 1. 2. 3. In addition to the c are provided by the MRP, all Kin Village residents are review ed by the Medic al Coord inator (MC). The MC is a physic ian w ho has particular interest and additiona l training and experienc e in c omplex residential c are. The MC has been engaged by KinVillage and the Fraser Health Authority. The MC prov ides oversight and makes recommendations for resident medic al c are. This oversight c an be provided at the disc retion of the c are staff , Direc tor of Hea lth Servic es, and MC at any time, not only during emergenc ies. The MC w ill strive to c ommunic ate w ith the MRP w hen attending to a resident. Please c hoose one of the follow ing: 1. 2. 3. 4. I am able to fulfill the MRP duties and w ish to be MRP. Dr _________________________ has c onsented to be MRP in my plac e. I w ould like to be MRP but request that the MC assist w ith c are c onferenc es medic ation reviews. I w ould like to request that the MC assume MRP for my patient. and Also, I w ould like to acc ept orphaned residents. Signature:___________________________________________Date:________________
  19. 19. Preparation = Medication-Specific Information as it relates to the resident BP behaviour sleep pain edema
  20. 20. How? A highly individualized process with resident-centered decision-making Beers Gallagher Other published guidelines
  21. 21. Guiding Questions Prognosis? Frailty? Goals? Medication Decision-Making
  22. 22. Strategy: Radical Pruning (Meds most often stopped) • • • • • Statins Osteoporosis Calcium Vitamins Unused prns
  23. 23. Strategy: Reducing and Streamlining Examples • Antihypertensives 3 • Diabetic meds dose 2 1
  24. 24. The Psychotropic Cocktail aka “Witch’s Brew”
  25. 25. Analgesics Convert to long-acting Stop acetominophen if requiring opioid Convert to patch Streamlining of Analgesics
  26. 26. Strategy: Simplification Eg. Constipation Switch from sennosides+lactulose+supps+enemas to PEG 3 1
  27. 27. Kin Village Medication Review Polypharmacy Reduction Initiative Re: Date: Dear Dr Today we reviewed your res ident’s me dication profile us ing curre nt polypharmacy reduction strategies and c linica l assessment. We recommend disc ontinuing medications that are deemed harmful, unnecessary, or of dubious benefit in the frail, e lderly residentia l population. We recommend reviewing dosages of medications and poss ibly decreasing them. We recommend re moving unused prn medications from the medication list. We are also attempting to simplify the reside nt’s drug regimen. Re comme ndations It is a pleasure working with you in caring for this resident. We welcome your comments and feedback. Yours truly, Christine Geme inhardt, Medica l Coordinator, 604-317-8721 Edwin Lee, Pharmac ist, 604-943-9341 Nadine Brown, RN, Clinical Practice Leader, 604-943-0155
  28. 28. Complex Communication Levels: Med Review Team to nursing staff Nursing to family Med Coordinator to family Med Coordinator to community GP Nurse to community GP Community GP to pharmacist Nurse to pharmacist Etc
  29. 29. Challenges with “Jumpstart” • • • • • • • Time commitment Nursing routine disrupted Orders generated Nursing staff buy-in Community physician buy-in Consultant visits Sustainability YES!
  30. 30. Sustainability - results # meds/resident Start 12 mo 9.0 6.2 6.7 6 mo
  31. 31. Long Term Sustainability New resident review 1 week (informal review) 6 month formal Team review Care conference 2 months (Informal review)