How to do it ... Resident medication management
1. Familiarize yourself with new regulatory language that places special mandates on drug regimen reviews and the medication reconciliation process.
“With the newly established CMS Requirements of Participation, the enhanced focus on polypharmacy, unnecessary medications and medication-related adverse events in the elderly have resulted in expansion of medication management processes across multiple care transition points,” notes Frank Grosso, RPh, executive director and CEO of the American Society of Consultant Pharmacists. He strongly urges using the expertise of a consultant pharmacist.
2. Adopt best practices that are proven. Grosso says successful medication management should tap into specialized training in geriatric pharmacotherapy.
“Having specific geriatric-related resources is important to have on-hand for doctors, nurses and pharmacists,” adds Sandy Hebert, director of product management for PointClickCare.
3. There are proven methods to mitigate addictive and psychotropic drug reactions. Grosso asserts that “non-pharmacological approaches to medication management should be incorporated into the care plan whenever possible.” He also advises thorough pain assessments when opioids are involved and “sleep hygiene” techniques when hypnotics are prescribed.
Prescribing sleep aids can indeed be a common issue, says McGill University researcher Marnie Wilson, M.D. Recently, she worked on a study where patients over age 60 were given a pamphlet on ceasing sedatives after a hospital visit. Two-thirds of those enrolled were able to stay off the sedatives at 30 days post-discharge. One of the big misconceptions is how long seniors need to sleep, she notes.
“Five to six hours can be fine,” Wilson says. “A sleep aid to get someone to eight to ten hours isn't reasonable. Education can go a long way.”
The “Keep Walking” program also was successful at reducing sedative hypnotics and benzodiazepines, says Rhett Barker, PharmD, BCGP, director of operations at Guardian Pharmacy Mid-South, a member of the Guardian Pharmacy Services family. “The activities director coordinated a program where volunteers from the community walked with residents around the halls of the facility or the paths outside the facility when possible.”
Hebert warns against complacency.
“The most common mistake care providers make in their attempt to avoid an adverse drug event, such as dependence, is believing that what they are currently doing is sufficient,” she says, urging regular audits to avoid such issues. Focusing more on detecting side effects such as cognitive impairment also is a plus.
4. Don't forget about over-the-counter meds a resident might be taking, says T.J. Griffin, chief pharmacy officer for PharMerica. The company is working with Purdue University researchers to conduct a study on the effects of polypharmacy.
“Don't focus on just prescription meds,” Griffin says. “Do a deep dive on the over-the-counters as well.”
For example, it's easy to forget how “Grandma likes to take St. John's wort or turmeric capsules. The latter has serious, dangerous interactions with warfarin,” he warns.
5. Barker believes successful medication management in the long-term care setting starts during transitions. His best practices list includes using pharmacy providers and pharmacy consultants in the medication reconciliation process.
One option is to have a caregiver observe a med pass where the nurse shows each medication to the resident and the family member, Barker says. Other proven safety measures include instituting brightly colored indicator vests and sashes for those performing the medication pass, and the STOPP-START toolset, which includes screening criteria for inappropriate medications and under-treatment, respectively.
6. Another best practice calls for digital efficiency.
Have an electronic health record system and clinical decision support tools within a computerized prescriber order entry system, which allows for drugs meeting Beers Criteria for potentially inappropriate medication use in older adults to be flagged, says Doris Yee, PharmD, a clinical pharmacist in the Consumer Drug Information Group at First Databank Inc.
Other recommendations include labeling systems that are consistent, user friendly and easy to identify regarding medication and dosage, preventing confusion and frustration, says Joe Kramer, vice president of sales and marketing at Gericare Pharmaceuticals.
Automated dispensing machines can track medications and provide verification, says Brian McNeill, CEO of Touchpoint Medical.
— John Hall