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Teamwork Needed To Improve Medication Safety in PA/LTC

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  • Author Footnotes
    1 Dr. Brandt is a professor of geriatric pharmacotherapy, pharmacy practice and science at the University of Maryland School of Pharmacy, and director of clinical and educational programs of the Peter Lamy Center for Drug Therapy and Aging, Baltimore. She is the president-elect of the American Society of Consultant Pharmacists (ASCP). She seeks to optimize the care of older adults through educational, clinical, and health care policy.
    Nicole J. Brandt
    Footnotes
    1 Dr. Brandt is a professor of geriatric pharmacotherapy, pharmacy practice and science at the University of Maryland School of Pharmacy, and director of clinical and educational programs of the Peter Lamy Center for Drug Therapy and Aging, Baltimore. She is the president-elect of the American Society of Consultant Pharmacists (ASCP). She seeks to optimize the care of older adults through educational, clinical, and health care policy.
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  • Author Footnotes
    1 Dr. Brandt is a professor of geriatric pharmacotherapy, pharmacy practice and science at the University of Maryland School of Pharmacy, and director of clinical and educational programs of the Peter Lamy Center for Drug Therapy and Aging, Baltimore. She is the president-elect of the American Society of Consultant Pharmacists (ASCP). She seeks to optimize the care of older adults through educational, clinical, and health care policy.
      The use of antipsychotic medications has been an ongoing target for scrutiny due to concerns about appropriateness and safety in older adults with dementia. Recently, the U.S. Government Accountability Office released a report (www.gao.gov/products/GAO-15-211) documenting antipsychotic medications that are frequently prescribed to older adults with dementia. Pharmacists can assist in increasing outreach and educational efforts aimed at reducing antipsychotic drug use in this population.

      Three Steps to Better Care

      As a pharmacist practitioner within a continuing care retirement community, as well as a member on an interprofessional dementia care team, it is my perspective that pharmacists could be employed more effectively through the following examples:
      • 1.
        Inclusion on behavioral health teams. Pharmacists can be instrumental in assisting with the following:
        • Obtaining details about the patient and his or her symptoms and risks.
        • Determining appropriateness of proposed treatment by matching patient-specific details to the known indications and the potential complications of a treatment.
        • Considering medications after ruling out potentially remediable causes of symptoms (e.g., pain, adverse effects of medications) and trying to limit use to individuals whose symptoms are severe enough to adversely affect function and quality of life.
        • Monitoring often enough to identify benefits and complications in a timely way.
        • Trying to use the lowest effective dose for the shortest possible duration, based on findings in the specific patient.
        • Trying to taper the medication when symptoms have been stable at least for several months or adjusting doses to obtain benefits with lowest possible risk.
        • Monitoring closely for adverse consequences that can be attributed to the medications (e.g., falls, worsening confusion) and reduce or stop doses if adverse consequences are identified.
          Examples of documentation to support this care process include: Multidisplinary Medication Management Committee Antipsychotic Use in Dementia Assessment (http://bit.ly/19MLhS0) and the Alliant GMCF Patient at Risk Form (PAR) for Antipsychotic Medication Reduction (http://bit.ly/1DrFZZF).
          Furthermore, pharmacists can assist with providing quality assurance (QA) reports that can help facilities and practitioners understand how they are meeting the needs of the patients they serve. These can then be compared with Nursing Home Compare data, but caution needs to be employed when interpreting how the public data are presented (http://go.cms.gov/1FmfHWi).
      • 2.
        Educational initiatives/training. Pharmacists can provide ongoing educational programs targeting prescribers, staff, and family or caregivers. Examples of initiatives that have been successful include academic detailing to prescribers, in-services to care staff, and education to caregiver support groups. Examples of handouts that may be useful for these various target audiences are the Antipsychotic Medication Reference (http://www.mdqio.org/docs/Antipsychotic_Tool.pdf) and the American Health Care Association and National Center for Assisted Living Quality Initiative Fast Facts: What You Need to Know About Antipsychotic Drugs for Persons Living with Dementia (http://bit.ly/1BRXdIJ).
      • 3.
        Care planning discussions. During an individualized care plan meeting, a resident’s conditions, abilities, needs, routines, and goals are discussed and folded into a plan of care. It has been noted in an Office of Inspector General report (http://oig.hhs.gov/oei/reports/oei-07-08-00151.pdf) that high-risk medications such as antipsychotics are not adequately addressed in the care plan. Pharmacists can assist in this effort and national clinical service initiatives, such as medication therapy management (MTM) may be able to meet this clinical need. MTM is a patient-centric and comprehensive approach to improve medication use, reduce the risk of adverse events, and improve medication adherence. MTM programs include interventions such as comprehensive medication reviews to engage the patient, caregiver, and their prescribers. This was discussed at AMDA’s 2015 Annual Conference and the handout is available at: www.prolibraries.com/amda.
      Ongoing monitoring and changes to care plans are critical because many side effects emerge early on in the treatment course that could lead to negative outcomes, such as falls or a decrease in day-to-day function. Outside of nursing homes, family members and caregivers may not understand why antipsychotics are being used, let alone how to identify if their loved one is benefiting from the medication. These types of issues can be targeted and addressed during an MTM encounter, as well as in the community.

      CMS Initiatives

      The Centers for Medicare & Medicaid Services has established reduction goals of 25% by the end of 2015, and 30% by the end of 2016, in the use of antipsychotic medications in long-stay nursing home residents. A recently launched portal at cms.gov, National Partnership to Improve Dementia Care in Nursing Homes (http://go.cms.gov/1BUzyZ3), provides numerous resources that can support the aforementioned approaches. Furthermore, CMS has included the use of antipsychotics in calculating the Five Star ratings on the Nursing Home Compare website (http://go.cms.gov/1CfAA0L).
      It is critical that we work together to improve awareness across all settings of care to ensure appropriate use of all medications including, but not limited to, antipsychotics. This column in the future will detail how pharmacists can help address these concerns.