Inter CGP. College. Objectives: AL SUPPORT. with manufacturer(s) this presentation..

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1 10 th Annual Spring Conference Arizona Geriatrics Society Person-Centered Care: An Inter rprofessional Panel Jeannie K. Lee, PharmD, BCPS, College of Pharmacy, The University of Arizona CGP Learning Objectives: Discuss person-centered medication management. Describe person-centered integrative healthcare. DISCLOSURE OF COMMERCIA AL SUPPORT Jeannie K. Lee, PharmD, BCPS, CGP does not have a significant financial interest or other relationship with manufacturer(s) of commercial product(s) and /or provider(s) of commercial services discussed in this presentation.. The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent 2017 Arizona Geriatrics Society All Rights Reserved 1

2 PERSON- CENTERED CARE AN INTERPROFESSIONAL PANEL MEDICATION MANAGEMENT & INTEGRATIVE HEALTHCARE JEANNIE LEE, PHARMD, BCPS, BCGP, FASHP UNIVERSITY OF ARIZONA COLLEGE OF PHARMACY OBJECTIVES 1. Describe person-centered medication management 2. Describe person-centered integrative healthcare Provide resources 2

3 BALANCING ACT OF PRESCRIBING What are potential benefits? What are potential risks? What does the patient prefer? AGE ASSESSMENT TOOL TO CALCULATE PHYSIOLOGIC AGE 5 Beers Criteria 2015 Update A list of medications or medication classes potentially inappropriate for older adults Risk > Benefit Free online publication Interprofessional communication tool Sex Difference in Risk of PIMs Community-dwelling women at 16% higher odds of receiving PIMs Benzos & other hypnotics, TCAs, NSAIDs Morgan SG, et al. Age Ageing. 2016;45(4):

4 RENAL DOSING (2015 AGS BEERS CRITERIA +) Medication CrCl (ml/min) Medication CrCl (ml/min) action required action required Cardiovascular or hemostasis Central nervous system and analgesics Duloxetine <30 Amiloride <30 Apixaban <25 Gabapentin <60 Dabigatran <30 Levetiracetam 80 Edoxaban 30-50; <30 or >95 Pregabalin <60 Enoxaparin <30 Tramadol <30 Fondaparinux <30 Hyperuricemia Rivaroxaban 30-50; <30 Colchicine <30 Spironolactone <30 Probenecid <30 Triamterene <30 Antimicrobials GI Almost all agents need to assess Cimetidine <50 Other Famotidine <50 Metformin: egfr<45-lower dose, egfr<30-d/c Glyburide: egfr<60-not recommended Nizatidine <50 Sitagliptin: CrCl<50-max50, CrCl<30-max25 Ranitidine <50 Atenolol: CrCl<35-max50, CrCl<15-max25 Alendronate: CrCl<35-not recommended Risedronate: CrCl<30-not recommended Allopurinol: CrCl<20-max200, CrCl<10-max100 DEPRESCRIBING.ORG CANADIAN DEPRESCRIBING NETWORK (CADEN) Which Drugs to Deprescribe? Risks associated with continued use Questions about ongoing indication or benefit Prevalence of overuse, challenge in stopping Availability of other treatment options Proton pump inhibitors Benzodiazepines and Z-drugs Antihyperglycemics Antipsychotics (coming soon!) EMPOWER BROCHURES Educational materials that explain why it might be important to stop certain medications Provide a step-wise tapering protocol when required Sedative-hypnotic brochure Proton pump inhibitor brochure Sulfonylurea brochure Antipsychotic brochure Antihistamine brochure 4

5 MEDSTOPPER.COM Deprescribing resource 1. Frail Elderly? 2. Generic or Brand name 3. Select Condition Treated Tips for Deprescribing in the Nursing Home Liu LM, Campbell IG. Annals of Long-Term Care: Clinical Care and Aging. 2016;24(9): Polypharmacy-Time to Get Beyond Numbers 1. Comprehensive, portable, and truly informative medication list Patient helps to maintain 2. Team approach to monitoring medication effectiveness and safety Include pharmacists 3. Real patient engagement, supported by whole health care team Include health coaches Steinman MA.. JAMA Internal Med. 2016;176(4):

6 Integrative Healthcare Alternative: Nonconventional strategies used in place of conventional interventions Complementary: Nonconventional strategies use together with conventional interventions Integrative: Bringing together conventional and complementary approaches in a coordinated way 13 NATIONAL CENTER FOR INTEGRATIVE PRIMARY HEALTHCARE Focusing on Interprofessional Education, Collaborative Practice and Evaluation INTERPROFESSIONAL LEADERSHIP TEAM Chair: Ben Kligler, MD, MPH Principal Investigator: Patricia Lebensohn, MD Project Director: Audrey Brooks, PhD The Consortium: Maryanna Klatt, PhD, RYT Preventive Medicine: Eden Wells, MD, MPH, FACPM Asim Jani, MD, MPH, FACP Family Medicine: Victoria Maizes, MD Internal Medicine: Ana Marie Lopez, MD, MPH, FACP Pediatrics: Hilary McClafferty, MD, FAAP Nursing: Mary Jo Kreitzer, PhD, RN, FAAN Mary S. Koithan, PhD, RN, CNS-BC, FAAN Pharmacy: Jeannie K Lee, PharmD, BCPS, CGP Public Health: Doug Taren, PhD Behavioral Health: Robert Rhode, PhD Academic Collaborative for Integrative Health: Elizabeth Goldblatt, PhD, MPA/HA HRSA Project Officer: Irene Sandvold, DrPH, FACNM, FAAN 6

7 IH CORE COMPETENCIES FOR PRIMARY CARE PROFESSIONALS 1. Practice patient-centered and relationship-based care. 2. Obtain a comprehensive health history which includes mind-body-spirit, nutrition, and the use of conventional, complementary and integrative therapies and disciplines 3. Collaborate with individuals and families to develop a personalized plan of care to promote health and well-being which incorporates integrative approaches including lifestyle counseling and the use of mind-body strategies. 4. Demonstrate skills in utilizing the evidence as it pertains to integrative healthcare. 5. Demonstrate knowledge about the major conventional, complementary and integrative health professions. 6. Facilitate behavior change in individuals, families and communities. 7. Work effectively as a member of an interprofessional team. 8. Engage in personal behaviors and self-care practices that promote optimal health and wellbeing. 9. Incorporate integrative healthcare into community settings and into the healthcare system at large. 10.Incorporate ethical standards of practice into all interactions with individuals, organizations and communities. SUB-COMPETENCIES - CONTRIBUTING DISCIPLINES Primary Care Residencies: Family Medicine Internal Medicine Pediatrics Preventive Medicine Nursing Pharmacy Public Health Licensed CIH Programs Acupuncture and Oriental Medicine Chiropractic Naturopathic Medicine Behavioral Health Physician Assistants 7

8 FOUNDATIONS IN IH COURSE - UNITS Introduction to Integrative Health in Primary Care Prevention and Lifestyle Behavior Change Healthcare Professional Wellbeing Addressing Patients through an Integrative Lens in Primary Care Integrative Interventions Community Settings & Systems at Large Final Reflection FOUNDATIONS IN IH PILOT STUDY 75 pilot sites 119 Site Leaders 2,207 Course Participants Faculty/Clinical Staff n=492; Trainees n=1,715 PILOT ENROLLEES BY PROGRAM TYPE Program Type N Program Type N Community Centers 930 Family, Preventive & Occupational Med 29 Integrative Medicine 323 Physician Assistant 28 Family Medicine 303 Chiropractic 27 Complementary Integrative Health 115 Internal Medicine/Pharmacy 24 Nursing 113 Preventive Medicine/Public Health 19 Medical School 55 Behavioral Health 15 Primary Care 47 HRSA 14 Pharmacy 44 Psychiatry 9 Preventive Medicine 43 VA Medical Center 3 Internal Medicine 32 General Medicine 2 Oriental Medicine 30 Physical Therapy 1 8

9 TIMELINE Revised course available online, free of charge, through August 31, 2017 (end of grant) Entire Course Available for Institutional Enrollment October 31, 2016 Individual Units Available for Individual Enrollment December 2016 For more information - info@nciph.org PATIENT HANDOUTS BILINGUAL, FOLLOW HEALTH LITERACY GUIDELINES Heart Disease Hypertension Hyperlipidemia Obesity Depression Anxiety ADHD Sleep Disorders Headache Eczema Fibromyalgia Chronic Fatigue Syndrome Fatigue Irritable Bowel GERD Constipation Asthma Allergies URI Diabetes Chronic Pain Pain Back Pain Arthritis Cancer Healthy Lifestyle PRACTITIONER NETWORK FOR UNDERSERVED Collaborating with Integrative Medicine Access (IMA) Online resource that provides education about Integrative Medicine and connects low-income persons with practitioners from 26 different health-care modalities who offer their services for very low cost to members who show proof of low-income status Creating networks in: Los Angeles, CA; Portland, OR; Minneapolis- St. Paul, MN; New York, NY 9

10 AVOID TOO MANY Alternatives Vague history or symptoms OTC medications have side effects too Interaction (drug-drug, drugdisease) Duration Therapeutic vs. Preventive Once a day vs. multiple times a day Other prescribers Money Adverse effects of other drugs Need Yes/No (Is this person actually taking the medication?) 10