MEDICATION CARE PLANNING

Keith WhiteClinical Lead, Medication Reconciliation

Chris RauscherClinical Lead, Seniors Care

Patient

Community-PAD

-PPh-2014/15

Hospital-MedRec

- 48-6-PPh

Residential Care-MedRec

-PPh-CLeAR

TiC

MedRec=Medication Reconciliation-Best Medication HistoryPPh=Shared Care Polypharmacy-Most appropriate management-med review

CLeAR=Call for Less Antipsychotics in Res care-Most appropriate mgt48-6=Assess 6 areas within 48 hours, includes meds

TiC=Transitions in Care, includes meds-Communication for planningPAD=Professional Academic Detailing in GP Offices-Med Knowledge

Med-Related Initiatives-Commonalities

• Purpose: Patients/Residents– Quality of life and safety, overall

management, not just meds

• Purpose: Medication Use – Appropriate, effective, reduce adverse

drug events

• Assessment, care planning, monitoring and review– Core functions across the initiatives

Medication-Related Initiatives

• BCPSQC – Clinical Care Management• MedRec• 48-6

– CLeAR

• MOH / BCMA Shared Care Committee• Polypharmacy in Elderly• Transitions in Care

– Provincial Academic Detailing

Medication-Related Initiatives

• Most are relatively new initiatives so need to bring together at initiative and local practice levels

• Medication-related initiative workshop– Optimizing Medications: Time to bring

the pieces together– January 16 & 17, 2014 in Vancouver– Announcement & registration coming

later this month

Medication Reconciliation in Residential Care

• Medication Reconciliation in long- term care is a formal process of:

• At admission, obtaining a best possible medication history (BPMH), which is a complete and accurate list of each resident’s current and preadmission medications - - including name, dosage, frequency and route.

• Using the BPMH to create admission orders or comparing the list against the resident’s admission orders, identifying and bringing any discrepancies to the attention of the prescriber for resolution.

• Any resulting changes in orders are documented and communicated to the relevant providers of care and resident or family member wherever possible.

Medication Reconciliation…

• Is the foundation for:–more accurate medication review

• Q6month reviews (physician, nursing, pharmacist)

• Clinical review for appropriate prescribing– Polypharmacy in the Elderly algorithm– CLeAR

• Is an important process to improve communication during re-admissions to residential care– Transfer to and from an acute care stay

Shared Care Polypharmacy

• “Medication Review” is the basic technology

• “De-prescribing” but can also be for prescribing, not only “indication” but decide in relation to other meds- ADEs

• “Supported” decision-making– Algorithm– Targeted drug classes–Med review opportunities– Clinical information

Shared Care Polypharmacy

• Phase 1-Prototyping 8 care facilities in BC

• Phase 1A (2013/2014)- Expand care facilities

• Phase 2 (2013/2015)- Acute Care/Transitions

• Phase 3 (2014/2015)- Community

Shared Care Polypharmacy

DRAFT 2023-04-10

RC Med Reviews Opportunities

• Occasions for Full RC Medication Reviews– Scheduled Med Reviews – regular, but effective?– When first admitted – or during admissions process– Transitions – e.g. from Acute/ED, Special Care Unit– Review of Level of Intervention – or equivalent– Review of “standing orders” – e.g. Gravol 50mg

• Occasions for Focused RC Medication Reviews– Episode of decline – symptom-directed, e.g. fall,

delirium– Request by staff – e.g. behaviour, med concerns, etc– Request by resident/family – education opportunity

11Addressing Polypharmacy in the Elderly

Priority Drug ListDrugs associated with:

• Confusional States

– antipsychotics, antidepressants, opioid analgesics, hypnotics• Adverse Drug Event-related Falls

– antipsychotics, antidepressants (tricyclics), hypnotics, antihypertensives, hypoglycemics, anticonvulsants, antiparkinson meds, antihistamines

• Significant Anticholinergic Effects

– antidepressants (tricyclics), antihistamines, bladder meds• Bleeding

– warfarin, antiplatelet meds• Indications Not Present (or no longer present)

– statins, PPIs, analgesics, antihypertensives, antianginals, antipsychotics, antidepressants, osteoporosis meds

Addressing Polypharmacy in the Elderly

Supports For Drug Review Decisions

• Guide individualized consideration of patient-at-hand– Drug Advisory Sheets [drafts]

PPIs ANTIPSYCHOTICS STATINSHYPNOTICS ANTIHYPERTENSIVES

ANTIDEPRESSANTSBISPHOSPHONATES VITAMIN D & CALCIUM SUPPLEMENTS

– Drug Brief: Calcium

• Understanding of clinical condition– Condition Advisory Sheets

STROKE PREVENTION IN THE ELDERLY (DRAFT)DEPRESSION IN THE ELDERLY (DRAFT)TREATING DIABETES IN THE FRAIL ELDERLY (FORTHCOMING)

Materials are aligned with GPAC and OPUS materials – and will be reviewed by a Clinical Advisory Team

Addressing Polypharmacy in the Elderly 13

48-6 in Acute Care

• Hospitalized seniors (aged 70 and older) • Integrated care initiative which

addresses six care areas of functioning: medications, cognitive, mobility, bowel/bladder, nutrition, pain

• Patient screening Assessment Individualized care plan, started within 48 hours if decision to admit Discharge and/or transition plan

48-6 in Acute Care

• To reconcile all medications on admission and at discharge and to limit risk for medication reconciliation errors during transitions in care.

• To complete an informed medication review to address potential medication adverse events.

• To prevent adverse medication events in hospital.• To optimize the medications and simplify the

regimens to make it easiest for the senior to adhere to their medication plan, making as few errors as possible.

Transitions in Care

• Shared Care Committee-Physicians + Health Authority initiatives

• Reduce re-admissions• Communication• Medications- 48-6, MedRec, Med Review• Involving Patients and Families- Patient

Passport

PAD

• Provincial Academic Detailing• Ministry of Health- Pharmaceutical Services• In depth drug information in GP offices• One drug class per period- Statins, Antibiotics,

etc.• Interested in partnering for med-related

initiatives

CLeAR

• Main focus BPSD and antipsychotic medications but take a holistic view of the resident

• Assessment, care plan with non-pharmacologic management approaches, monitoring and review Algorithm

• Inter-relates to other medication-related initiatives

Patient

Community-PAD

-PPh-2014/15

Hospital-Med Rec

- 48-6-PPh

Residential Care-MedRec

-PPh-CLeAR

TiC

MedRec=Medication Reconciliation-Best Medication HistoryPPh=Shared Care Polypharmacy-Most appropriate management-med review

CLeAR=Call for Less Antipsychotics in Res care-Most appropriate mgt48-6=Assess 6 areas within 48 hours, includes meds

TiC=Transitions in Care, includes meds-Communication for planningPAD=Professional Academic Detailing in GP Offices-Med Knowledge

Bringing Med-Related Initiatives Together-Care

Scenario• Mrs. Brown is an 86 year old widowed woman,

with a moderately severe Alzheimer disease, who has been recently admitted to your residential care facility from community.

• Meds: Ramipril, Atorvastatin, Furosemide, Warfarin, Donepezil, Venlafaxine, Zopiclone, Thyroxine, Alendronate, Calcium, Vit D, Esomeprazole (Nexium)

What med-related initiative is applied at admission and how?

How else can meds be reviewed after an admission?How does this relate to care planning?

Care Scenario

• A few months later, Mrs. Brown is not eating well and she appears to be more confused. She has a fall and she is sent to hospital.

• What med-related initiatives would apply at her hospital admission and how would various approaches be integrated?

• Mrs. Brown has a delirium and she is agitated so Risperidone is started. She settles in hospital and is discharged to facility.

• What med-related initiatives apply at this transition stage and how will they be inter-related?

Care Scenario

• The Risperidone was stopped after a few days in the care facility as it was thought that the agitation was in relation to a delirium. She returns to prior status.

• A few months pass and Mrs. Brown is getting agitated with verbal aggressive behavior when getting care.

• What would be the approach to care planning at this time, through integration of what med-related initiatives?

General Discussion

How Can We Promote the Integration of the Various Med-

Related Initiatives?

Polypharmacy Contact information

• Website– www.bcma.org/polypharmacy-initiative

• Contacts: Keith White, Physician Lead, Polypharmacy

• E-mail: Shared_care@bcma.bc.ca