10-(5) Smith Examples of a Not So Typical Day (recorded) · 4/10/2020 · 11. Sucralfate 1gm four times a day for GERD (>2yrs) 12. Magnesium oxide 400mg daily (>2yrs) 13. Metoprolol

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Examples of a “Not so Typical Day” as a Consultant Pharmacist

Michele Smith, PharmD., CPh, has disclosed that she has no relevant financial disclosures. No one else in a position to control content has any financial relationships to disclose.

Disclosure Statement

The University of Florida College of Pharmacy is accredited by the Accreditation Council for Pharmacy

Education as a provider of continuing pharmacy education.

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At the completion of this activity, the participant will be able to:

• Describe a not so typical day of consulting pharmacy in a variety of practice settings

• Identify methods of problem solving as a consultant pharmacist in specific practice environments

Objectives

Nursing Homes

• Monthly Responsibilities–Medication Regimen Review for each resident

–Medication Observation Pass

–Nursing Unit Inspection–Narcotic Drug Destruction–Monthly Reports

NH Consultant Pharmacist of Record

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• Medication Regimen Review for each resident– Review physician orders– Labs, Vitals–MAR/TAR

– Clinical Notes–Other: Assessments, H&P, Hospital Transfer Records…


• Examples of what to look for during a Medication Regimen Review– Appropriate indications, doses– Drug interactions, duplicate therapy

–Monitoring

– Deprescribing opportunities


• Medication Observation Pass

– Inspect supplies– Observe various routes of

administration– Observe documentation– Crushing, liquids, dilution, infection

control– Educate


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• Nursing Unit Inspection–Medication carts• Narcotic count audit

– Treatments carts

–Medication room

–Refrigerator– Sink area


• Narcotic Drug Destruction–Perform with DON or review documentation of completed destruction


• Monthly Report–Recommendations to Physicians

–Recommendations to Nursing

– Summary Report

–Other relevant reports– Sent to DON, Administrator, Medical Director


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• Quarterly Responsibilities Include

–Prepare Quarterly Report

–Attend Quarterly CQI meeting

–Provide Quarterly Drug Information


• Other Responsibilities Include– Interim MRRs

–Available during surveys, answer questions, problem solve

–Provide updates on regulations–Attend other meetings

–Provide additional reports


Obvious reasons to consider Deprescribing in NHs

Carr, T. Too Many Meds? America's Love Affair With Prescription Medication. Consumer Reports.org. https://www.consumerreports.org/prescription‐drugs/too‐many‐meds‐americas‐love‐affair‐with‐prescription‐medication/. Published August 3, 2017.

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1. Approximately 40% of NH residents receive >9 medications

2. Up to 30% of hospital admissions for patients >75 y.o. are medication related and 75% are potentially preventable

Background

Administration for Community Living. Administration on Aging. https://acl.gov/about‐acl/administration‐aging Klarin, I et al. The association of inappropriate drug use with hospitalization and mortality: a population‐based study of the very old. Drugs Aging. 2005;22: 69‐82

The process of identifying and discontinuing medications that are unnecessary, ineffective, and/or inappropriate in order to reduce polypharmacy and improve health outcomes.

Deprescribing

1. No indication 2. Ineffective3. Too risky 4. Actual increased risk‐ patient is

experiencing side effects5. Potential increased risk‐ patient likely to

experience adverse drug events6. Course completed 7. Poor medication adherence8. Diminished benefit

When to stop a medication?

Scott I.A., et al. JAMA Intern Med. 2015;175(5):827‐34.

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1. Recognize a reason for discontinuing medication

2. Identify and prioritize the medications targeted for discontinuation

3. Discontinue, communicate with patient and other providers

4. Monitor effects

Deprescribing Protocol

Bain et al. JAGS 56:1946‐1952

A medication should be stopped when the following are identified:

A. No indication

B. Ineffective

C. Too risky

D. Patient is experiencing side effects and adverse drug events

E. All the above

Assessment Question

1. PPIs2. Anticholinergic & sedative burden (i.e.

psychotropics)3. Polypharmacy regimens for specific

diseases4. Beers criteria drugs5. Nonprescription and herbal

medications

Target Medications for Deprescribing

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1. Beers Criteria for Potentially Inappropriate Medication

2. Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP)

3. Screening Tool to Alert doctors to the Right Treatment (START)

Deprescribing Tools

American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J AM Geriatr Soc 2015; 63:2227‐2246O’Mahony D, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 2015; 44(2):213‐218

Scott, I MBBS, FRACP, MHA, MEd. Reducing Inappropriate Polypharmacy. The Process of Deprescribing. JAMA Intern Med. 2015: 175(5): 827‐834

Deprescribing Algorithm

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Liu L et al, Annals of Long‐Term Care: Clinical Care and Aging. 2016;24(9):26‐32. Received December 27, 2015

Liu L et al, Annals of Long‐Term Care: Clinical Care and Aging. 2016;24(9):26‐32. Received December 27, 2015

Give an example of a tool used in Deprescribing.

Assessment Question

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1. Prescriber

2. Director of Nursing / Nurse manager

3. Consultant Pharmacist

4. Risk Manager

5. Social Services

NH Deprescribing Team

BB is an 83 y.o. female admitted to a SNF. She has Alzheimer’s disease for approximately 8 yrsand has been cared for by her husband at home. Her past medical history include: Type 2 DM, hypertension, osteoarthritis, depression, urinary incontinence, GERD, hyperlipidemia, insomnia, CAD, chronic kidney disease, history of falls. Complaint of: GI distress, drowsiness, dizziness, BB presents to facility confused, sentences disorganized not related to current place, people events, incontinent of both bowel and bladder. No symptoms of depression and denies pain (scale: 0/10) She has trouble swallowing pills and is cachectic

Question: What medications can we deprescribe? In what order?

Deprescribing Case Example

Recent Labs:

Hg A1C: 6.1%

BG: range 100‐120

LDL: 65

HDL: 70

TG: 110

Total Cholesterol: 170

SCr 1.6 mg/dL

GFR 23mL/min

BIMS: 2 (BIMS score interpretation: 0 – 7 Severe cognitive impairment; 8 – 12 Moderate impairment; 13 – 15 Intact cognitive response)

Weight 90 lbs (loss of 10 lbs in last year)

Deprescribing Case cont.

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10. Omeprazole 20mg daily for GERD (>2yrs)11. Sucralfate 1gm four times a day for GERD (>2yrs)12. Magnesium oxide 400mg daily (>2yrs)13. Metoprolol tartrate 50mg twice a day (>5yrs)14. Hydrochlorothiazide 25mg daily15. Ibuprofen 600mg three times a day (>2 yrs) 16. Trazodone 50mg at bedtime PRN (>5yrs)17. Dilantin 100mg daily (>5yrs)‐ sub therapeutic dose (adult dose: 100mg tid=300mg daily)

1. Donepezil 10mg daily for dementia (>5 yrs) 2. Memantine 10mg twice a day for dementia (>5yrs)3. Amitriptyline 50mg daily (>2 yrs) – no indication4. Oxybutynin 10mg daily for urinary incontinence (>2

yrs)5. Lovastatin 40mg at bedtime for high cholesterol

(>5yrs)6. ASA 81mg daily for CAD (>5yrs)7. Sliding Scale Insulin Humulin Regular BG 61‐150= 0

units; 151‐200=3 units; 201‐250=5 units; 251‐300=8 units; 301‐350=10 units; 351‐400=12 units and Cal MD. Call MD for BG <60 or >400 for Type 2 DM (hospital discharge medication)

8. Seroquel 12.5mg at bedtime for insomnia (>2yrs)9. Sertraline 25mg daily for depression (>5 yrs .

Prescribed after the death of her son)


Considerations:1. Anticholinergic: amitriptyline, oxybutynin, Seroquel2. GI Distress: donepezil, memantine, Ibuprofen, lovastatin, phenytoin3. Sedating: amitriptyline, trazodone, Seroquel, sertraline, Dilantin4. Long QT syndrome: donepezil, Seroquel, HCTZ, sertraline5. Indications: amitriptyline, Insulin, Seroquel, trazodone, MgOx,

Ibuprofen, Dilantin6. PRN medications – SS insulin, trazodone 7. Drug Interactions – amitriptyline/trazodone/sertraline,

phenytoin/Seroquel


Part 1:

• Taper and discontinue: amitriptyline, Seroquel, donepezil and memantine, Zoloft

• Stop: lovastatin, magnesium, HCTZ, sertraline, S/S insulin, Ibuprofen, PRN Trazodone, sucralfate

• Follow up: assess for pain, depression with weight loss, insomnia

Part 2:

• Obtain medical hx for seizures and clarify need for phenytoin

• Trial taper off omeprazole, ranitidine when other issues stabilized

Deprescribing case

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• Minimum Data Set

• A standardized assessment tool‐measures health status of nursing home residents in MCR and MCD certified nursing facilities

• Required for payment of Skilled Nursing Facility stays

MDS ‐What is it?

• It is a part of a federally mandated process for clinical assessment of all residents in MCR or MCD certified nursing homes

MDS ‐Why is it important?

• Assessment

• Care planning

• Quality indicators / Quality measures

• Reimbursement

MDS Impacts

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• Based on responses to MDS

• Assist Nursing home in identifying potential problems in caring for the residents

Quality Measures Reports

Certification And Survey Provider Enhance System

CASPER ‐What is it?

1. MDS 3.0 Facility Characteristic Report

2. MDS 3.0 Facility QM Report

3. MDS 3.0 Resident Level QM Report

4. MDS 3.0 Submission Statistics

(4) CASPER QM Reports Available

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• Assist nursing home staff in:

‐Identifying potential problem areas in the facility

‐Identify problems specific to a resident

• Utilized by surveyor in preparing for survey to:

‐Identify potential problems with care

‐Select residents for chart review

Why are CASPER reports important?

• (2) CASPER reports essential to QAPI process

‐Facility Quality Measure Report‐Resident Level Quality Measure Report

• QAPI: Quality Assurance (QA) and Performance Improvement (PI)

‐A comprehensive approach to ensuring high quality care.

CASPER Reports

• What is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes? This process includes a comprehensive, standardized assessment of each resident's functional capabilities and health needs.

A) CASPER

B) MDS

C) QAPI

Assessment Question

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Case Example

1. How many Quality Measures (QMs) does Resident B triggered?

2. What Quality measure can you address to improve Resident

B’s overall condition?

Assessment Questions for Case Example

• If antipsychotic drug is on the medication list, determine the appropriate diagnosis

• Resident receiving AP will trigger for off‐label use UNLESS the person has Schizophrenia, Huntington’s disease, Tourette’s Disorder

• Make sure the AP is designed to treat a mental illness and not used in response to behaviors

• Why and when was the AP medication started?

• Discontinue AP for residents who do not have mental illness

Strategies to reduce AP for Short Stay

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• Teamwork! – Prescribers, DON, Nurses, MDS coordinator, Social

workers, activities staff, families, CPh

• Review CMS Survey Guidance

• Behavioral intervention• Consistent staff assignments

• Meaningful activities

• Provide one‐to‐one care• Tracking, trending

Strategies to reduce AP for Long Stay

www.medicare.gov/NursingHomeCompare

• Nursing home State Survey (AHCA) reports

• Nursing home Five‐Star quality rating system

‐Rating: 1 to 5 stars (5 stars= above avg; 1 star=below avg)

• Locate nursing homes by name, zip code, state & city

• Provide nursing home specific Quality Measures and compares them to state and national percentages

Nursing Home Compare

Center for Medicare & Medicaid Services. Finding a Nursing Home. www.medicare.gov/NursingHomeCompare

Nursing Home Compare ‐www.medicare.gov/NursingHomeCompare


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• Review full inspection report including pharmacy tags

• Assist nursing home with Plan Of Correction (POC) if needed

• Assist nursing home with audits for compliance with POC

• Assist nursing home with preparations for re‐survey

Post State Survey

(ICF/IID)

INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES (ICF/IID)

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• Client Profile

• Commonly seen disease states

• Day Programs

• Monthly Visits

– Inspections

–MRRs

ICF/IID

Rehab Facility

• Client Profile

• Commonly seen disease states

– Addiction Recovery

– Buprenorphine

• Monthly Visits

– Inspections

– Documentation

Recovery Facility

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Correctional

Facilities

• Juvenile Detention Centers

• County Jails

• State Prisons

Correctional Facilities

• Types of Medication

• Monthly Visits

– Inspections

–Monthly Report

Correctional Facilities

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• Carr, T. Too Many Meds? America's Love Affair With Prescription Medication. Consumer Reports.org. https://www.consumerreports.org/prescription‐drugs/too‐many‐meds‐americas‐love‐affair‐with‐prescription‐medication/. Published August 3, 2017.

• Administration for Community Living. Administration on Aging. https://acl.gov/about‐acl/administration‐aging

• Klarin, I et al. The association of inappropriate drug use with hospitalization and mortality: a population‐based study of the very old. Drugs Aging. 2005;22: 69‐82

• Scott I.A., et al. JAMA Intern Med. 2015;175(5):827‐34.

• American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J AM Geriatr Soc 2015; 63:2227‐2246

• O’Mahony D, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 2015; 44(2):213‐218

• Scott, I MBBS, FRACP, MHA, MEd. Reducing Inappropriate Polypharmacy. The Process of Deprescribing. JAMA Intern Med. 2015: 175(5): 827‐834

• Liu L et al, Annals of Long‐Term Care: Clinical Care and Aging. 2016;24(9):26‐32. Received December 27, 2015

• Center for Medicare & Medicaid Services. Finding a Nursing Home. www.medicare.gov/NursingHomeCompare

References

Examples of a “Not so Typical Day” as a Consultant Pharmacist

10-(5) Smith Examples of a Not So Typical Day (recorded) · 4/10/2020 · 11. Sucralfate 1gm four times a day for GERD (>2yrs) 12. Magnesium oxide 400mg daily (>2yrs) 13. Metoprolol

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