jigsaw 101: meidcation initiative in action polypharmacy in the elderly

KinVillage Polypharmacy Reduction Pilot Project

“The Jumpstart”

Christine Gemeinhardt, MD, MSc, CCFP

Medical Coordinator

January 16, 2014

Disclosure Statement

No conflict of interest

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

Results January 2013 – June 2013

Time 0

Total # meds/99 residents

897

Meds/resident

9.0

6 months

Total # meds/99 residents

659

Meds/resident

6.7

Change in Meds - Pilot Project

2.3 per resident

26%

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

The Team

Med Review Team

Medical

Pharmacist

Clinical Practice

Leader

Director, RNs, LPNs

Project Medication

Reviews

“Jumpstarting”

Intensive Work:

33 residents/week

4-5 minutes/resident

2 ½ hours per session

Weekly sessions X3

99 residents

Pre-requisites for Rapid Fire Med Reviews!

“Jumpstart” Med Review Timeline

Start 0

3 months

6 months

Process – Pharmacist Medication Count

Time 0

January 2013

6 months

June 2013

Post project follow up

12 months

January 2014

Our Pharmacist, Our Hero

KinVillage Polypharmacy Reduction Pilot Project

Basic premises

Frail residents are at the end

of their life cycle

Focus on quality of life,

not cure or longevity

Residents receive too

much medication

“Medication focus” wastes

valuable nursing time

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

Attrition of community physicians

Aging and semi-

retirement

Travel time, inconvenience,

too few residents

Lack of interest,

other areas of commitment

Physician Agreement

Attrition

Unable to accept or

meet requirements

Physician Agreement

Engaged

Accept

KinVillage Physician Agreement

Dear Dr _______________________, Date: __________________

Your patient, _________________________________, is now a resident of KinVillage -

Complex Residential Care.

Each resident at KinVillage has a Main Responsible Physician (MRP). The MRP is asked to

fulfill the following duties:

1. Be available to reconcile the resident’s medications the day of admission

2. Visit the resident within 2 weeks of admission

3. Visit the resident routinely on a quarterly basis, review with nursing staff, and write

legible chart notes 4. Provide timely onsite assessment and care when the status of the resident changes

5. Provide timely onsite assessment prior to initiating transfer to hospital and communicate

with the Emergency Physician

6. Meet with the resident’s representative(s) in person to complete the MOST (Fraser Health

Medical Orders for Scope of Treatment) within a week of admission. 7. Meet with 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 multidisciplinary care conferences.

10. Provide a replacement MRP when unavailable

In addition to the care provided by the MRP, all KinVillage residents are reviewed by the Medical Coordinator (MC). The MC is a physician who has particular interest and additional

training and experience in complex residential care. The MC has been engaged by KinVillage

and the Fraser Health Authority. The MC provides oversight and makes recommendations for

resident medical care. This oversight can be provided at the discretion of the care staff, Director

of Health Services, and MC at any time, not only during emergencies. The MC will strive to communicate with the MRP when attending to a resident.

Please choose one of the following:

1. I am able to fulfill the MRP duties and wish to be MRP. 2. Dr _________________________ has consented to be MRP in my place.

3. I would like to be MRP but request that the MC assist with care conferences and

medication reviews.

4. I would like to request that the MC assume MRP for my patient.

Also, I would like to accept orphaned residents.

Signature:___________________________________________Date:________________

Preparation = Medication-Specific Information

as it relates to the resident

BP

pain

edema sleep

behaviour

How?

A highly individualized process with resident-centered

decision-making

Beers

Gallagher Other published guidelines

Guiding Questions

Medication Decision-Making

Goals?

Frailty?

Prognosis?

Strategy: Radical Pruning

(Meds most often stopped)

• Statins

• Osteoporosis

• Calcium

• Vitamins

• Unused prns

Strategy: Reducing and Streamlining

Examples

• Antihypertensives 3 2 1

• Diabetic meds dose

The Psychotropic Cocktail aka “Witch’s Brew”

Analgesics

Streamlining of

Analgesics

Stop acetominophen

if requiring opioid

Convert to

long-acting

Convert to patch

Strategy: Simplification

Eg. Constipation

Switch from

sennosides+lactulose+supps+enemas

to

PEG

3 1

Kin Village Medication Review

Polypharmacy Reduction Initiative

Re: Date:

Dear Dr Today we reviewed your resident’s medication profile using current polypharmacy reduction strategies and clinical assessment. We recommend discontinuing medications

that are deemed harmful, unnecessary, or of dubious benefit in the frail, elderly residential population. We recommend reviewing dosages of medications and possibly decreasing them. We recommend removing unused prn medications from the medication list. We are also attempting to simplify the resident’s drug regimen.

Recommendations

It is a pleasure working with you in caring for this resident. We welcome your comments

and feedback. Yours truly,

Christine Gemeinhardt, Medical Coordinator, 604-317-8721 Edwin Lee, Pharmacist, 604-943-9341 Nadine Brown, RN, Clinical Practice Leader, 604-943-0155

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

Challenges with “Jumpstart”

• Time commitment

• Nursing routine disrupted

• Orders generated

• Nursing staff buy-in

• Community physician buy-in

• Consultant visits

• Sustainability YES!

Sustainability - results # meds/resident

Start

9.0

6.7

6 mo

12 mo

6.2

Long Term Sustainability

New resident review 1 week

Care conference 2

months

(Informal review)

6 month formal Team

review

(informal review)