Transforming Care for the Elderly

Transcription

1 Transforming Care for the Elderly Session 2: Engaging Pharmacists & Interdisciplinary Care Teams to Improve Prescribing of Antipsychotics & to Reduce Polypharmacy January 11, 2017

2 Welcome With us today: Host Jennifer Major Senior Improvement Lead, CFHI Alistair Bursey Pharmacist Jean Coutu Pharmacy Fredericton, 4 Krista Millette-Rocan Certified Geriatric Pharmacist Jean Coutu Pharmacy Fredericton, NB Dr. Paula Rochon Senior Scientist, Women s College Research Institute Vice President, Research, Women s College Hospital Professor, Department of Medicine, University of Toronto Retired Teachers of Ontario Chair in Geriatric Medicine, University of Toronto

3 Objectives for today s webinar At the end of today s webinar, we hope that you can: Understand CFHI s Appropriate Use of Antipsychotic Intervention - which we have supported organizations to tailor through our pan-canadian & New Brunswick Appropriate Use of Antipsychotics collaboratives Identify strategies you can use in your organization to improve pharmacist and interdisciplinary team engagement in healthcare improvement initiatives Describe typical prescribing cascades and implications for medication review Describe how innovative pharmacy practice models can improve prescribing and care outcomes in the elderly 5

4 CFHI s pan-canadian Appropriate Use of Antipsychotic Collaborative: May 2014-Oct

5 CFHI and NBANH New Brunswick Appropriate Use of Antipsychotics (NB-AUA) Collaborative: May 2016 ongoing 15 homes have been participating since February, 2016 The rest of the long term care homes in the province will join in February, 2017 Select acute care units and special care homes (home care) will also join in the spring,

6 Pan-Canadian & NB-AUA Collaborative Objectives: Reduce inappropriate use of antipsychotics in nursing homes Improve the quality and experience of dementia care for nursing home residents, families and staff Build individual and organizational capacity in designing, implementing, evaluating, sustaining and spreading resident-centred and data-driven dementia care innovations 8

7 The Pan-Canadian & NB-AUA Intervention Core components of the intervention the LTC homes tailored to their context included: 1. Education to all staff to increase skill to devise and deliver person-centered approaches to care 2. Multidisciplinary team work and communication between families, leadership, physicians, pharmacists, and all other front line staff 3. Regular medication reviews at least quarterly, but more frequently during reductions 4. Ongoing data collection & analysis 5. De-Prescribing guidelines including behavioral tracking 9

8 Pan-Canadian & NB-AUA Collaborative Team Membership & Composition Project Lead (e.g. DoC) Evaluation and Measurement Lead (e.g. data analyst) Executive Sponsor Clinician Lead (e.g. Nurse, Physician, Pharmacist) Family Member or Resident Representative 10

9 The Pan-Canadian & NB-AUA Collaborative Support 11

10 Pan-Canadian AUA Collaborative Results: Better Health Outcomes Baseline Sept 2014 Q-1 Dec 2014 Q-2 Mar 2015 Q-3 Jun 2015 Number of Target Residents discontinued or reduced (54%) 222/ Falls Verbal Abusive Behaviours Aggressive Behaviour no increase Resisting Care Socially Inappropriate Behaviours Similar results are trending in the NB-AUA collaborative to date (15 homes). 12

11 Pharmacist Engagement in Practice: York Care Centre case example York Care Centre is a 214 bed home in Fredericton, New Brunswick, & part of the pan-canadian AUA collaborative. Initial target residents for reduction = 11/25 in one unit. Results: 3 discontinued, 6 reduced = reduction rate of 89% Krista Millett was the lead pharmacist on the Quality Improvement team at the organization. 13

12 Up Next: Next, we will hear from pharmacist Krista Millett about: The role she played as a critical member of the quality improvement team at York Care Centre, a 214 bed LTC home, to improve prescribing of antipsychotic medications in CFHI s Pan-Canadian AUA collaborative Recommended strategies to engage pharmacists to improve prescribing Tips & suggestions for promoting engagement of the quality improvement team Project Lead (e.g. DoC) Evaluation and Measurement Lead (e.g. data analyst) Executive Sponsor Clinician Lead (e.g. Nurse, Physician, Pharmacist) 14 Family Member or Resident Representative

13 1. How have you engaged pharmacists in initiatives to improve prescribing? Use the chat function to type in your response. 15

14 Pharmacist Engagement in Practice: York Care Centre case example Pharmacist role on the York Care Centre Quality Improvement Team included, for example: 1. Participated in & informed all medication reviews to identify candidates for reduction 2. Devised titration schedules (with tailored reduction schedules) and appropriate therapies 3. Available to the core quality improvement team and all staff to advise other pharmaceutical alternatives. 4. A champion to all staff and families to communicate the importance of appropriate use of antipsychotic medication (to improve resident quality of life & minimize medication waste). 5. Helped engage & communicate with physicians (champions and non-champions) & families 6. Lead & facilitated some of the staff education sessions - For example, de-prescribing guidelines, safe titration, dosing adjustment protocols, finding lowest effective dose 16

15 Pharmacists as Partners: Some Best Practices Incorporate evidence-based principles Pharmacist contribution should align with their scope of practice or expertise Include pharmacist in resident reviews, interdisciplinary meetings, etc. 17

16 Promoting Engagement of the Quality Improvement Team Tips & Suggestions for Managers: Establish a regular meeting or touch base with your quality improvement team (including physician partners if you can) Act as a liaison Intervene as necessary in MD/RN issues Sponsor joint education and joint celebratory events Be present during rounds Work with individual MDs to build collegial relationships 18

17 Promoting Engagement of the Quality Improvement Team Communication with physicians should be factual and brief. For example, concisely show and/or communicate: Current list of medications Any noticed side effects from the antipsychotics Hx of the antipsychotic use (how long, any changes in the med/dose, reaction) MDS outcome indicators Behaviors and potential causes (from behavioural tracking or other assessment) Pharmacists can play an important role in conversations with prescribers, as participants and/or informants. 19

18 How do prescribing cascades impact medication review processes & physician/pharmacist engagement? Senior Scientist, Women s College Research Institute Vice President, Research, Women s College Hospital Professor, Department of Medicine, University of Toronto Retired Teachers of Ontario Chair in Geriatric Medicine, University of Toronto 20

19 Case 1: Mrs. X Mrs. X was diagnosed with dementia Started on atypical antipsychotic for management of behavioural problems associated with dementia 21

20 Case 1: What did we know Over the next several months Mrs. X has slowing of gait 22

21 Her physician prescribes anti-parkinsonism therapy to treat Parkinson s Disease Is this a problem? 23

22 The Origin of Prescribing Cascade A "prescribing cascade" begins when an adverse drug reaction is misinterpreted as a new medical condition Rochon PA, Gurwitz JH. BMJ

23 The Origin of Prescribing Cascade Rochon PA, Gurwitz JH. Lancet

24 What is a Prescribing Cascade? Prescribing cascades: common examples of adverse drug events which have gone unnoticed and can be prevented Initial Drug Therapy New Medical Condition New Drug Treatment Further Medical Condition Incontinence Develops in weeks to months Not well recognized as drug-related Perhaps confused with age-related changes Rochon PA, Gurwitz JH. BMJ 1997 Time 26

25 Prescribing Cascade Examples Initial Drug Therapy Side Effect New Drug therapy initiated Misinterpreted as a New Medical Condition Antipsychotics Parkinsonism Antiparkinsonian agents Cholinesterase Inhibitors Urinary incontinence Urinary Anticholinergics agents Gabapentin Edema Diuretics agents Metoclopramide Parkinsonism Antiparkinsonian agents Non steroidal anti inflammatory drug (NSAID) Hypertension Antihypertensive agents Thiazide and Thiazide-like diuretics Gout 27 Anti-gout agents

26 Key Steps to deprescribing: 1. Ascertain all drugs the patient is currently taking and the reasons for each one 2. Consider overall risk of drug-induced harm in individual patients in determining the required intensity of deprescribing intervention 3. Assess each drug for its eligibility to be discontinued Prescribing cascade 4. Prioritize drugs for discontinuation 5. Implement and monitor drug discontinuation regimen Scott IA, Hilmer SN, Reeve E, et al. Reducing Inappropriate Polypharmacy: The Process of Deprescribing. JAMA Internal Medicine

27 Preventing Prescribing Cascades Periodically review medication regimens of all older people Discontinue medications when no ongoing need Consider adverse drug effects as a potential cause for any new symptom Consider non pharmacologic first Consider a reduced dose Rochon & Gurwitz, Lancet

28 How Innovative Pharmacy Practice Models can Improve Prescribing and Outcomes Alistair Bursey 30

29 Pharmacists - Key Community Partner Expert in medication therapy Key ally for prescribers in communities Majority of patients access pharmacy first Undergoing key practice changes to utilize skill-set to maximum potential. NBPA - Photo Stock 31

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31 Advanced Pharmacy Practice 33

32 Advanced Pharmacy Practice 34

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34 Questions? Please submit your questions/comments electronically using the Chat Box on the bottom of your webinar screen. 36

35 Upcoming Webinars January 27 th We Belong International Forum: Experiences, Recommendations and Next Steps from Indigenous Youth February 8 th Transforming Care for the Elderly Session 3 of 3 February 22 nd CFHI s Open Call for Innovations in Palliative Care REGISTER NOW

36 Thank you!