Medication management: Five things to do better
Terri Fagan, director of clinical services at Consonus Pharmacy
As a geriatric pharmacist, helping keep patients safe, improving the quality of their care and reducing the risk of hospitalizations has been my professional motivation for almost 27 years. It's what I love and do, all day every day, and it's also what true medication management is all about.
That's why I'm optimistic about the positive impact the new rules of participation from the Centers for Medicare & Medicaid Services can have. Though long-term care facilities will experience unnerving transitions and increased compliance pressures, your consultant pharmacists will be invaluable partners at every step. And our shared commitment to the well-being of those we serve will continue to be what drives our mutual success.
Moving the needle
As we prepare for the next phase-in of the Final Rule, the complexities of establishing and maintaining an effective medication management program can be a bit overwhelming. So as a place to start, I'm proposing five specific areas in which facility leaders, clinical staff and consultant pharmacists can work together to move the needle and do things even better.
1. Reduced antipsychotic use
The long-term care profession's national successes in reducing antipsychotic use are impressive and well known, but as regulatory impact increases, even more education and focus is required.
Except in rare situations, antipsychotic medications simply shouldn't be used for behavioral and psychological symptoms of dementia (BPSD) without an assessment for an underlying cause of the behavior.
2. Better antibiotic stewardship
Up to 70% of nursing home residents receive one or more courses of systemic antibiotics in a year, and the Final Rule rightly focuses on the importance of creating more comprehensive antibiotic stewardship programs and adopting best practices.
For example, a positive urine culture obtained without clear signs or symptoms localized to the urinary tract has been shown to be of limited value, and has contributed to the overuse of antibiotic therapy for chronic asymptomatic bacteriuria (ASB). This leads to an increased risk of negative outcomes, possible drug resistance and high costs.
3. Effective diabetes management
There are many ways better medication management can improve care for those with chronic diseases. With type 2 diabetes, there is little evidence that using medications to achieve tight glycemic control is beneficial for most older adults. In fact, the practice has consistently been shown to produce higher rates of hypoglycemia.
One way to reduce that risk is to eliminate the use of sliding scale insulin and longer acting oral hypoglycemic agents. CMS has also released a trigger tool to evaluate for adverse drug events with high risk medications.
4. Safer care transitions
Poor medication management is one of the most significant factors contributing to unnecessary hospital readmissions, and transitions of care offer many opportunities for improvement. Using an interdisciplinary team approach, with close nurse/consultant pharmacist collaboration, can help ensure patient safety and decrease costs.
It is estimated, for example, that 60 percent of the adverse drug events that occur after hospital discharge could be prevented or improved with the careful reconciliation of all pre- and post-discharge medications—something the Final Rule requires. A good place to start would be with a focus on the most frequently prescribed medications with the highest risk for harm—Warfarin, insulin and opioids.
5. Elimination of unnecessary medications
Frankly, we can all do a better job in long-term care at avoiding unnecessary medication use in older adults. Medications are sometimes ordered with an overestimate of benefits and an underestimate of risks, and duplicate therapy, excessive dose and duration, and inadequate monitoring are common additional challenges.
All-too-frequently, a new medication is added to treat a side-effect of an existing medication, creating a prescribing cascade or “poly-prescribing.” A motto I've lived by through my entire consultant pharmacist career is that any new symptom in an older patient should be considered a drug side effect until proven otherwise. Embracing that concept and deprescribing where possible will limit adverse drug events and improve patient outcomes.
The challenge—and the opportunity
With these five areas of possible focus, we've only scratched the surface of the potential that exists for better medication management. The ultimate goal of any such program, of course, should be to ensure patient safety and positive clinical outcomes, improve quality measures and compliance, and reduce costs without compromising care. As consultant pharmacists, we're proud to be partners in this vital effort.
Terri Fagan, R.Ph, is a certified geriatric pharmacist with more than 20 years of long-term care pharmacy experience. She's the director of clinical services at Consonus Pharmacy, where she leads a team of 25 consultant pharmacists serving 325 facilities in five states.