Drive to Deprescribe Journey: Just Getting Started

      When AMDA – The Society for Post-Acute and Long-Term Care Medicine launched its Drive to Deprescribe (D2D) initiative in May 2020, the goal was a 25% reduction of medication use in PALTC. What evolved was a movement that united interdisciplinary teams, empowered practitioners, and generated energy and positive change. It took a proactive approach to an issue that members are passionate about addressing.
      “This is quite a unique program. This wasn’t triggered by mandates. This is an issue that our membership have strong feelings about and want to address in a significant way,” said Arif Nazir, MD, CMD, chief medical officer at Signature HealthCARE (SCH) and president of SHC Medical Partners. In fact, he suggested, “It’s actually not an initiative anymore. Initiatives are nice but not sustainable. This has become part of our day-to-day work at Signature and elsewhere. We talk about it all the time. We have meetings with our directors of nursing every week, and they say it’s one of the most important things we’ve done.”
      Michael Cinque, PharmD, senior vice president of pharmacy management at Genesis, noted, “One of the most rewarding aspects of D2D has been hearing from other disciplines because the medication use process is not just about prescribing. We can make greater strides toward improvement when teams work together.” He added, “D2D drives performance.”
      Sabine von Preyss-Friendman, MD, FACP, CMD, chief medical officer of Avalon Healthcare, said, “There is a lot of evidence out there, but it takes time to implement it in practice. We want to speed this up. Through our monthly meetings, there is an opportunity to share the latest evidence and data quickly.”
      Although this is a Society effort, Dr. Nazir said, “Many people participating in D2D aren’t AMDA members, but this issue resonates with them. It is important for AMDA to find issues that speak to people beyond our membership. We’ve consistently had 90–100 people on our webinars, but the same individuals didn’t always participate every time.” This, he suggested, indicated D2D’s breadth and reach.

      From How-To to How-to-Track

      The D2D program made available deprescribing pamphlets that align with evidence-based deprescribing guidelines and algorithms to provide lay-level information that helps patients and caregivers have conversations with their prescriber about safe deprescribing. To date, there are pamphlets on deprescribing for proton pump inhibitors, benzodiazepines and Z-drugs, antihyperglycemics, and antipsychotics. There also are deprescribing guideline infographics on these topics.
      “Medical directors set the expectations, and operations managers set the framework. Then there needs to be a great deal of teaching and collaboration as a team,” said Dr. von Preyss-Friedman. Getting the buy-in of team leaders is essential, but this calls for some encouraging data. “This is where our pharmacy dashboard comes in. We can look at this and see where there are outliers and problems. Incorporating this into our QAPI [Quality Assurance Performance Improvement] process also helps.”
      It is challenging to collect data from an initiative like D2D where many facilities and practitioners are involved and not all of them on a monthly basis. Dr. Nazir observed, “We are getting good feedback from the D2D participants, but defining the impact on paper has been challenging. We have created much needed awareness of polypharmacy and deprescribing issues, but we don’t yet have the data we need.” Dr. Cinque said, “We need to focus on specific D2D participating organizations that are truly engaged and work with their pharmacies to collect needed data.”
      Dr. Cinque has created a scorecard in spreadsheet form for his organization that captures a variety of details, including how quickly the prescriber responds to the pharmacist’s recommendation and the percentage of residents taking a specific medication (e.g., antipsychotics). From this scorecard, facilities can see if they are better than average, average, 10% below average, 10% to 25% below average, or more than 25% below average. He said, “I am targeting data points that I know our centers are seeing from their pharmacies. I’m color coding and rolling it out to enable clinical leaders at the market level to see where they stand and where improvements can be made.”
      According to Dr. Cinque, anyone can build a scorecard for their facility or practice related to specific issues that matter to them. This doesn’t have to be complex. “It’s perfectly okay to start with a few metrics,” he said. At the least, he suggested, “Every facility should be looking at the number of scheduled, PRN [as needed], and total medications for patients.” He added, “Facilities can do this with what they have, but we need to create tools that allow leadership to guide and influence the performance of their facilities wherever they are and however larger or small they are. Then we need to recognize and praise great performers and help those at the bottom figure out where changes and improvements can be made.” He stressed that there needs to be accountability across the board.

      Shoring Up Staffing

      D2D not only is helping participants reduce polypharmacy and improve care for residents but also is helping staff. For instance, throughout the pandemic, nurse managers often found themselves consumed by medication administration. Thanks to D2D, facilities have been able to reduce the number of medications residents are taking. Dr. Cinque said, “Reducing med pass time is a business imperative. It is a hard win.” For instance, he worked with one facility that went from an average of 12 scheduled medications to 9.8. This is improving med pass time, which is critical to improving patient care and frees nurses to do the work they love.
      Maximizing teamwork, engagement, and communication is another benefit of D2D. As Dr. Cinque said, “This initiative has helped bring pharmacists, nurses, advanced practice practitioners, and physicians together. The consultant pharmacist is doing work that is valuable, and the prescribers need to work with them — they are your partners.”
      In addition to improving staffing relationships and teamwork, D2D also has helped improve communication with families. Dr. von Preyss-Friedman said, “The tools and resources we’ve provided help practitioners develop good channels of communication with families and encourage empathetic listening. This is what goes into successful family communication.”

      The Road Ahead

      Although much has been accomplished, Dr. von Preyss-Friedman stressed, “We aren’t done yet.” She indicated there are other medications that the initiative could address. “We got tied down by COVID. We have to catch up, and this model can go further.” She suggested, “We have a lot of knowledge at AMDA, but we can do more in terms of providing guidance on taking this effort and implementing it in practice.”
      As patients move through the continuum often quicker and sicker, nursing homes see higher acuity, and staff turnover is at all-time highs, D2D needs to be ongoing. “It isn’t one and done. The demand and need will continue to exist,” said Dr. von Preyss-Friedman. “We have many patients coming from the hospital on numerous medications and sometimes some potentially dangerous ones. This is constant.”
      D2D will live on through the many resources and tools developed through the initiative that are available on the Society’s website. In addition, the members of the D2D Leadership Team will continue to publish articles and make presentations about D2D and issues related to deprescribing. At the same time, the program has already created a legacy. As Dr. Nazir observed, “This initiative has validated the fact that there is no one person with a Superman cape to save the day. We need participation from all disciplines.” He added, “By the time we started this initiative, people were worn out by the pandemic. People didn’t have energy for a new initiative, yet many participated in D2D.” He added, “This effort made people feel empowered. At Signature, for example, we have more than 20 buildings that have cut pills by 10% to 20%, and they take great pride in this. They feel like they’re doing something good. They were able to get engaged, and they found it to be meaningful.”
      Senior contributing writer Joanne Kaldy is a freelance writer in New Orleans, LA.