I appreciate the opportunity that I have been given to take over this column from Dr. Jeffrey Nichols. For many years, Dr. Nichols offered an astounding amount of insight and good advice to Caring’s readership. In this column, I will do my best to carry on the Caring for the Ages tradition of practical, insightful, and direct thinking about controversial issues that are often dominated elsewhere by the conventional wisdom.
Dear Dr. Steve: Like most nursing homes, we get many new patients who are taking a lot of medications. We often have little useful information to help us determine why they are on them and whether they still need them. It seems that medications are often described as a problem in long-term care. I see many proposed programs and projects to try to address the issue. My facility has participated in some of these initiatives, but the problem seems to persist — if not worsen. Is there anything we can do to make a more definitive dent in the medication issue?
Dr. Steve responds:The OBRA Regs Revisited column in the June–July 2020 issue (Caring 2020;21:16–17) addressed the perennial challenges of medications in health care generally, and long-term care specifically. Medications have a profound impact on everything from organ function to thinking and behavior. As with so many things, medications can be highly beneficial when used appropriately and highly problematic when they are not. However, there are many inexpensive, definitive things facilities can do to develop comprehensive, enduring, and effective approaches to medications.
Acting in Real Time
Twenty-six years ago, an article about the effectiveness of geriatrics identified that “much of geriatric care is, in effect, remedial. It addresses problems produced by the care of others, errors of both commission and omission” (C. Boult, L. Boult, and R.L. Kane, “How Effective Is Geriatrics? A Review of the Evidence,” in P.R. Katz et al., eds., Quality Care in Geriatric Settings, Springer, 1995, 111). However, remediation is time consuming, often costly, and commonly addresses previously avoidable complications.
We cannot prevent all medication-related problems, of course, particularly those that are unpredictable and unavoidable. In such cases, a certain amount of retrospective review and correction is inevitable. However, many current approaches are only minimally preventive, so countless issues go undetected or unabated. The extent to which this results in costly remedial action is widely underestimated.
Simply looking up medications online could help minimize adverse consequences and improve recognition of those that occur, but far more could be done in regard to efficient and effective preventive approaches to medications. Most of it is remarkably inexpensive and involves doing basic things correctly, using available information, and holding people accountable for their performance.
A Comprehensive Approach
Projects, activities, and initiatives to improve medication-related issues have been given various names such as “deprescribing,” “medication reconciliation,” and “medication therapy management.” While these have some merit and may serve as an entry point into looking at medications, they are largely piecemeal approaches (e.g., antipsychotic medication reduction or admission medication reconciliation) and not very efficient.
The only truly viable approach to the medication issue is to stop treating it as another separate project or initiative and instead incorporate medication considerations into routine everyday practice. Through the years I have guided facilities in actively addressing medication risks and issues in real time, rather than waiting for predictable damage to occur or depending on others to bail them out.
Emphasize the Full Care Delivery Process
As the surveyor guidance from the Centers for Medicare & Medicaid Services notes, all medication management is “based in the care process and includes recognition or identification of the problem/need, assessment, diagnosis/cause identification, management/treatment, monitoring, and revising interventions as warranted as well as documenting medication management steps … The attending physician plays a key leadership role in medication management” (“Medication Management,” State Operations Manual, Appendix PP, rev. 173, CMS, 2017, 511).
Appropriate medication use starts with thoughtful and accurate problem definition and cause identification. As discussed in the March 2020 column on OBRA regulations updates (Caring 2020;21:10) and in the clinical practice guidelines and attending physician curriculum of AMDA – The Society for Post-Acute and Long-Term Care Medicine, the full care delivery process is the foundation for all care. It cannot be shortchanged or skipped.
Addressing medication-related issues is only sometimes about the medications themselves (e.g., indications or dosage); frequently it is about avoiding or correcting mistakes and omissions in clinical reasoning and problem solving (e.g., pain, falls, behavior, weight loss) that led to the problematic prescribing. An example would be the inappropriate prescribing of appetite stimulants (often based on unwarranted dietician recommendations) for anorexia and weight loss without first recognizing that many medications adversely affect gastrointestinal function and appetite.
In the facilities where I have served as medical director through the years, I have advised the staff and practitioners to always be suspicious that medication effects, adverse consequences, and interactions could be the cause of any symptom or condition change in any patient at any time. The possibility of adverse effects of medications should never be dismissed until it has been ruled out by a systematic thought process.
Limit Prescribing Silos
It is of course desirable to have multiple participants in patient assessment and care. However, everything going on with a person (including behavior) is the aggregate result of all internal and external factors, including medications. Judicious and safe medication use requires prescribing in context, based on the “big picture” for each patient, and not in silos controlled by multiple practitioners or consultants with insufficient coordination. Prescribing in silos is never a sound practice — often it is a recipe for harm.
While a facility cannot always coordinate or integrate all care immediately, it should have some built-in checks and balances to compensate for these limitations. For example, I guided nurses in long term care settings to regularly identify, report, and discuss orders of concern, regardless of the source, directly with the primary care practitioners. Although consultant pharmacists have a required regulatory role in such reviews, they cannot and should not be the sole source of them.
Strictly Limit Who Can Recommend or Request Medications
Even though they do not have the training and qualifications to reason through to the right conclusions, countless licensed staff (and even many administrators) casually suggest or recommend specific medications: “Call the doctor and get an order for Ativan” (or oxycodone, or another drug). But this is not a casual activity, and good intentions alone are not an adequate rationale. These requests are especially problematic when they are based on guesswork, and practitioners are heading down the wrong path when they assume — incorrectly — that the caller considered all the relevant issues before making the recommendation or request.
For example, recommendations to practitioners about psychiatric medications often come out of “gradual dose reduction” meetings attended by nurses, social workers, and consultant pharmacists, and these are based on little more than regulatory considerations. It is ill advised to make any recommendations about psychiatric medications unless we understand the cause of the underlying disorder and are aware that authoritative psychiatric references recommend ruling out medical causes and considering the possible adverse impact of existing medications before chasing psychiatric and behavior issues with more medications (Diagnostic and Statistical Manual of Mental Disorders, 5th ed. [DSM-5], American Psychiatric Association, 2013, 2).
As a medical director, I have advised medical practitioners to avoid being misled by staff and patient requests for specific medications. Instead, they should refocus everyone on thinking through and discussing the situation instead of rushing to guess about the treatment.
With good diagnosis and treatment selection, there should be relatively little need for major changes in pharmacological interventions “after hours” and on weekends. The principal staff and practitioners should scrutinize any such orders as soon as practical.
Scrutinize Medication Orders From Consultants
Although consultants (such as hospices, pain clinics, wound centers) can play a useful role in long-term care settings, it is essential to have their recommendations funneled through the primary care practitioner and long-term care team, who have a better understanding of the patient’s history and response to medications and other treatments. Consultants vary in their capabilities, qualifications, understanding of medications and geriatrics, and knowledge of the patient beyond the immediate symptom. Experience has taught me not to assume without at least some review that consultants necessarily know best, have taken all relevant information into account, or have made appropriate recommendations.
Strictly Limit “Phantom” Orders
In many nursing homes, the staff regularly write “phantom” orders — alleged “verbal” orders that were not actually obtained from the practitioner whose name is recorded as having given them (Caring 2009;20:14). This may be done to immediately implement a consultant’s nonemergent recommendation or order diagnostic tests (e.g., barium swallow, urinalysis, or albumin). Not infrequently a staff person may decide to give the patient supplements, appetite “stimulants,” or even antibiotics for positive cultures without consulting a medical practitioner. It is essential to curb this highly inappropriate and often dangerous practice.
Use Consultant Pharmacists Wisely, but Recognize Limitations
Consultant pharmacists have substantial training about many aspects of medications, and they are important members of the interdisciplinary team. Recent updates in surveyor guidance have required them to do even more, including intensified monthly reviews and a review of all new admissions. They provide another set of eyes to evaluate the potential risks and benefits of the use of medications.
However, patient care requires identifying medication indications in context and actual adverse consequences in real time. This requires knowing the patient’s detailed history and current symptom details, knowing the differential diagnosis of symptoms, and assimilating all this information to reach the right conclusions.
I have learned from reviewing many consultant pharmacist reports over the years that there is often a difference between commenting on drugs and commenting on the context of the drugs. For example, a consultant report may focus on the as-needed or standing dose of an opioid analgesic, but the real issue is whether the patient’s pain warrants the use of an opioid at all.
Because the escalating regulatory requirements have led to a huge number of such consultations, medical practitioners may be tempted to skip the details and just agree or disagree with the recommendations. But this would be missing the opportunity to identify a lot of important clinical and systems issues and definitively fix or prevent medication-related problems. In my experience, actually reviewing these consultations with a nurse practitioner who knows the patient is an effective, efficient way to find and address real issues in the all-important big-picture context.
Rather than relying too heavily on consultant pharmacists, expect your staff and primary care practitioners to take the main responsibility for learning about, identifying, and addressing the significant, active adverse consequences of medications. In my experience over many years and across many facilities, I have identified thousands of these problems through basic case reviews that no one else — including medical practitioners, surveyors, and consultant pharmacists — had recognized.
Look Things Up
I am often asked, “Who has the time to look anything up?” Too often staff and practitioners rely on memory, informal consultations, and their limited knowledge of medications, causation, and clinical reasoning. But we all have unprecedented easy and free access to a huge repository of information with details about medications and the meaning of symptoms — including those that may reflect adverse medication consequences.
Over the years, I have collaborated with many nurse practitioners and nursing staff to use Google to quickly look up reliable information that has helped improve care for our patients (Provider, June 1, 2020, 34-36; https://bit.ly/39xoCM5
). Examples of other helpful, free resources include the Beers list (J Am Geriatr Soc 2019;67:674-694), Medscape.com
, and the Medical Letter’s article “Drugs That May Cause Psychiatric Symptoms” (Dec. 15, 2008; http://secure.medicalletter.org/w1301c
I have found it invaluable to show key staff and practitioners how to do effective key word searches in real time to address active and complex medication-related situations. With practice, it becomes much more efficient and effective than waiting for a consultant or having to subsequently fix the complications of inadvisable or problematic practice.
Prescribing Is a Privilege
Recommending and prescribing medication is a solemn responsibility that has a profound impact on people’s lives. This privilege needs oversight, accountability, requirements, and limits.
There has been growing use of the term “prescriber” to describe individuals who write medication orders. However, this is as misguided as using the term “operators” to describe those who perform surgery.
Just like performing an operation, prescribing is (or should be) the end point of a diagnostic reasoning and problem-solving process. Choosing medications is as serious of a responsibility as recommending and performing surgery. Just as not all licensed surgeons are qualified to perform urologic surgery, only some licensed medical practitioners are adequately trained or skilled to prescribe opioids or psychopharmacologic medications.
It is an essential part of quality assurance performance improvement to set expectations and ask questions about practitioners’ knowledge and skill in making clinical decisions and prescribing medications. Even though practitioners may find it uncomfortable, feedback from the medical director and others is essential. And even good practitioners can improve significantly over time by taking advantage of such opportunities to learn.
Ultimately, a definitive approach to the issue of medications requires a substantial rethinking of current and traditional approaches in all settings, including — but not limited to — long-term and post-acute care. To the greatest extent possible, the approach to medications should be built into everyday practice rather than addressed by special additional projects and initiatives. Otherwise, it is unlikely that medication-related issues will ever substantially improve beyond their current status.
Dr. Levenson has spent 42 years working as a PALTC physician and medical director in 22 Maryland nursing homes and in helping guide patient care in facilities throughout the country.