Medication Safety during Transitions of Care: Clinical Implications Section 2.6: Tools to Improve Transitions of Care Processes This section is divided into 5 Parts: • Part 2.6.1: Care Transitions Tools • Part 2.6.2: Medication Reconciliation Tools • Part 2.6.3: Medication Management Tools • Part 2.6.4: Deprescribing Tools • Part 2.6.5: Risk Screening Tools Part 2.6.1: Care Transitions Tools National Transitions of Care Coalition (NTCC) The National Transitions of Care Coalition (NTCC) acknowledges the complexity of transitions of care. Poorly-defined responsibilities and ineffective patient hand-offs between care settings can poorly impact care delivery during this vulnerable time. Poor outcomes may include: wrong treatment, delay in diagnosis, severe adverse events, patient complaints, increased healthcare costs and increased length of stay. NTOCC created many tools for healthcare professionals to use to improve transitions of care within any care setting. • Patient medication list o Helps patients and caregivers keep providers informed of most up-to-date medication list • Patient Bill of Rights during transitions of care o Outlines information and services patients deserve • “Taking Care of my Healthcare” consumer tool o Guides patients and caregivers on what kind of information and questions to ask providers • Informational slide deck and brochure for consumers o Summarizes what transitions of care is and what NTCC tools are available • Implementation plan o Outlines the concepts, process and "how to" on implementing and evaluating a Transitions of Care plan • Transitions of care checklist o Helps enhance communication among health care providers, between care settings, and between clinicians and clients/caregivers 1
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Medication Safety during Transitions of Care: Clinical Implications
Section 2.6: Tools to Improve Transitions of Care Processes
This section is divided into 5 Parts:
• Part 2.6.1: Care Transitions Tools
• Part 2.6.2: Medication Reconciliation Tools
• Part 2.6.3: Medication Management Tools
• Part 2.6.4: Deprescribing Tools
• Part 2.6.5: Risk Screening Tools
Part 2.6.1: Care Transitions Tools National Transitions of Care Coalition (NTCC)
The National Transitions of Care Coalition (NTCC) acknowledges the complexity of transitions of
care. Poorly-defined responsibilities and ineffective patient hand-offs between care settings can
poorly impact care delivery during this vulnerable time. Poor outcomes may include: wrong
treatment, delay in diagnosis, severe adverse events, patient complaints, increased healthcare
costs and increased length of stay.
NTOCC created many tools for healthcare professionals to use to improve transitions of care
within any care setting.
• Patient medication list o Helps patients and caregivers keep providers informed of most up-to-date
medication list
• Patient Bill of Rights during transitions of care
o Outlines information and services patients deserve
• “Taking Care of my Healthcare” consumer tool
o Guides patients and caregivers on what kind of information and questions to ask providers
• Informational slide deck and brochure for consumers
o Summarizes what transitions of care is and what NTCC tools are available • Implementation plan
o Outlines the concepts, process and "how to" on implementing and evaluating a Transitions of Care plan
• Transitions of care checklist o Helps enhance communication among health care providers, between care
settings, and between clinicians and clients/caregivers
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• Importance of health information technology (HIT)
o Identifies HIT problems and considerations to improve overall transitions of
care • Medication reconciliation essential elements
o Outlines important considerations when implementing a medication reconciliation program to reduce medication errors
• Policy paper and Issue Briefs o Details vision of NTCC to improve transitions of care and guidance for improving
transition performance
• Cultural competency paper o provides information about culture, cultural competence, and strategies and
resources to enhance professionals’ capacity to deliver culturally competent services
Some of these practical tools are also available in Spanish or French translations.
• Resource: This link directs you to the NTCC tools and resources available for download:
Canadian Deprescribing Network Video: The steps involved in deprescribing – shared decision-making with patients This 55-minute video presented by Barbara Farrell, PharmD from the Canadian Deprescribing.org initiative focuses on the shared decision-making and patient engagement aspect of deprescribing conversations. It provides an evidence-based review of the shared decision-making process, impact on care, and barriers and enablers in conversations. Additionally, it describes in detail the steps in the shared decision-making process in the context of deprescribing and sample statements for each step.
Resource: Deprescribing.org. The steps involved in deprescribing - shared decision-making with patients. June 27, 2018. Retrieved from: https://www.youtube.com/watch?v=Ywzhd0cj7Ls&t=53s
Veterans Affairs Health System’s VIONE Deprescribing Tool
The Veterans Affairs (VA) Healthcare System developed a tool to provide guidance to clinicians and patients on deprescribing medications that are potentially or actually unsafe, not needed, or whose risks outweigh the benefits to promote patient safety and quality of life. It divides medications into five categories and provides decision-making action plans. The tool was shown to decrease pill burden, cost, side effects, medication errors, and ER and hospital visits while increasing freedom and quality of life.
Clinicians Patients
Vital Is the medication a life-saving medication?
Continue and adjust as needed
Is this medication vital and essential for my health?
Important Is the medication important for quality of life?
Continue and consolidate where possible
How important is this medication to improve my quality of life and my health?
Optional Does this medication make no major difference if it is continued?
Weigh risk vs benefits
Do I absolutely need to take this medicine or is it option?
Is it safe to stop this medicine or take it in smaller doses?
Not indicated Is this medication or treatment no longer indicated?
Stop or taper off medication
Am I taking any medications that are no longer appropriate or needed?
Can these be stopped or decreased?
Every medication has a reason
Every medication has to have a diagnosis and indication for use that is reassessed and justified.
Does every medication that I take have a clear reason or diagnosis? If not, is it important to ask my provider why I am taking it?
The VIONE workgroup can be reached at [email protected] with questions.
Primary Health Tasmania Deprescribing Guides
Primary Health Tasmania (Tasmania PHN) is a non-government, non-for-profit organization under the Australian Government’s Primary Health Networks Program. They provide targeted support for general practice through resources, professional development, training and networking. They have guides outlining deprescribing strategies for medicines including allopurinol, antihyperglycemics, antihypertensives, antipsychotics, aspirin, benzodiazepines, bisphosphonates, cholinesterase inhibitors, glaucoma eye drops, NSAIDs, opioids, proton pump inhibitors, statins and vitamin D and calcium. They also have a consumer-focused brochure to facilitate a conversation with providers about deprescribing, and a series of short videos about the deprescribing cycle.
The Good Palliative-Geriatric Practice algorithm was designed for nursing homes to
reduce polypharmacy. A series of questions determine whether drugs should be continued at the
same dose, reduce the dose, stop the drug, or switch to another drug. The algorithm assesses
if:
• Indication is valid and relevant
• Possible adverse reactions outweigh possible benefits
• Drug causing adverse signs or symptoms
• Another drug is superior
• Dose can be reduced without significant risk
When tested in nursing homes in Israel, the algorithm reduced mortality, hospitalization, and
cost with low rate of drug discontinuation failure.
• Resource: This is the citation for the Good Palliative-Geriatric Practice algorithm:
Garfinkel D, Zur-Gil S, Ben- Israel J. The war against polypharmacy: a new cost-effective
geriatric-palliative approach for improving drug therapy in disabled elderly people. Isr
Med Assoc J2007;9(6):430–4.
Deprescribing Studies
De-PRESCRIBE trial
In “Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults, The De-PRESCRIBE Randomized Clinical Trial”, Martin et al. outlined consumer-targeted, pharmacist-led interventions that resulted in greater discontinuation of inappropriate prescriptions (sedative-hypnotics, glyburide, and NSAIDs) compared with usual care after 6 months. Educational materials for patients consisted of a drug-specific brochures (i.e. sedative-hypnotics, sulfonylureas, NSAIDs). Educational materials for physicians consisted of pharmacist-physician communication sheets for each of the agents.
● Resource: Martin, P, Tamblyn R, Benedetti A, et al. “Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults, The De-PRESCRIBE Randomized Clinical Trial. JAMA. 2018;320(18):1889-1898.
EMPOWER trial
The EMPOWER (Eliminating Medications Through Patient Ownership of End Results) trial, reported by Tannenbaum et al, was conducted in community pharmacies using direct-to-consumer educational interventions against usual care to assess benzodiazepine therapy discontinuation among community-dwelling older adults over a 6-month follow-up period. The primary outcome is the complete cessation of benzodiazepines, or dose reduction (at least 25% reduction of baseline dose). The study group participants received a Canadian
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Deprescribing Network brochure, which describes the risks of benzodiazepine and hypnotic use, education about drug interactions, suggestions of therapeutic substitution for insomnia and anxiety, and step-wise tapering recommendations. Results showed 27% of study group participants achieved complete benzodiazepine cessation and 11% achieved dose reduction, compared to 5% and 6% respectively in the control group. Discouragement from their physicians/pharmacists or fear of withdrawal symptoms were the most common reason reported by those elected not to taper/stop. These results show the effectiveness in deprescribing utilizing direct-to-consumer interventions at the community pharmacy setting, highlighting the role of community pharmacists in the deprescribing of potentially problematic medications.
● Resource: Tannenbaum C, Martin P, Tamlyn R, Benedetti A, et al. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education. The EMPOWER Cluster Randomized Trial. JAMA Intern Med 2014;174:890-98. Doi:10.1001/jamainternmed.2014.949
Access full article through https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1860498
Institute for Healthcare Improvement: Publications on Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines
Innovation Case Study
McCarthy presents a case study about a multidisciplinary team of clinical experts who focused on developing and implementing deprescribing guidelines for tapering and stopping medications for elderly adults. The project and research team consisted of three researchers and four health care leaders who collaborated to create guidelines on how to implement a deprescribing process to discontinue unnecessary or inappropriate medications. They found that long-term care facilities adopted the implementation process more than community-centered family health teams and those that implemented the deprescribing guidelines found the process useful and that it also created an interdisciplinary approach to patients’ healthcare.
Implementation Guide
A multidisciplinary team of clinical experts from Ottawa, Canada adapted a deprescribing innovation adopted by a US healthcare system into a Deprescribing Implementation Guide. The guide consists of 4 phases: 1) Set-Up, 2) Develop the Scalable Unit, 3) Test Scale-Up, and 4) Go to Full Scale. The basis of the 4 phases is to establish a specific goal for deprescribing such as what medication will be deprescribed, how much reduction is needed, by what time frame, and in which population of patients. Based on that goal, a protocol must be developed to test on a small scale unit before using on a full scale unit in the healthcare system.
● Resource:
1. McCarthy D. Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017.
2. Pelton L, Knihtila M. Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines — Implementation Guide. Boston, Massachusetts: Institute for Healthcare Improvement; 2018.
Access with login through free account: http://www.ihi.org/resources/pages/publications/evidence-based-medication-deprescribing-innovation-case-study.aspx
Tools for Deprescribing in Frail Older Persons and those with Limited Life Expectancy
Thompson et al performed a systematic review of the literature to outline different deprescribing tools that can be used in frail older persons and those with limited life expectancy. They divided the tools into the categories of models/frameworks for approaching deprescribing, outlined a deprescribing approach when reviewing the entire medication list, and provided medication-specific advice. Additionally, throughout the article, the authors reference the tool, category of the tool, population of interest for the tool, and a brief description of it in an easy to read table format.
● Resource: This is the citation for the article:
Thompson W, Lundby C, Graabaek T, et al. Tools for Deprescribing in Frail Older Persons and those with Limited Life Expectancy: A Systematic Review. J Am Geriatr Soc 2019;67(1):172-180. doi: 10.1111/jgs.15616
Free PDF Access (https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.15616)
Health Care Professionals’ Attitudes Toward Deprescribing in Older Patients with Limited Life Expectancy: A Systematic Review
Lundby et al reviewed literature from inception through 2017 regarding deprescribing views in older patients with limited life expectancy. The authors identified eight studies exploring these views, mostly from the perspective of general practitioners. Four themes were identified regarding attitudes around deprescribing: (1) Patient and relative involvement, (2) The importance of teamwork, (3) Health care professionals’ self-assurance and skills, and (4) The impact of organizational factors. Some sub-themes included difficulties around cognitive impairment, pressures from family, reluctance to engage in collaborative care, lack of confidence and level of responsibility of practitioner, and staffing and workflow issues. Considering that few studies were identified and themes include multiple factors that are highly interdependent, it is the opinion of the authors that there is urgent need for more research in the area.
● Resource: This is the citation for the deprescribing and limited life expectancy article:
Lundby C, Graabaek T, Ryg J, et al. Health care professionals’ attitudes towards deprescribing in older patients with limited life expectancy: A systematic review. Br J Clin Pharmacol 2019 Jan 10 [Epub ahead of print]. DOI:10.1111/bcp.13861
PDF Version: https://bpspubs.onlinelibrary.wiley.com/doi/epdf/10.1111/bcp.13861
Feasibility Study of a Systematic Approach
Garfinkel et al performed a feasibility study on the Good Palliative-Geriatric Practice (GP-GP) algorithm in community-dwelling older patients. The goal of the study was to explore whether this algorithm could be implemented to reduce polypharmacy in older patients. Through patient assessment and incorporation of the GP-GP algorithm, clinicians had discussions with the patient/guardian to determine if deprescribing was appropriate. If discontinuing medications was inappropriate, other options included a dose reduction or shift to another drug. Favorable outcomes included discontinuation of 311 medications in 64 patients. The authors comment that this study may be limited due to the small sample, which may not be representative of the heterogeneous population, and there was no data to assess if patients were treated inappropriately before the study was done.
● Resource: Garfinkel D, Mangin D. Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults: Addressing Polypharmacy. Arch Intern Med. 2010;170(18):1648–1654. doi:10.1001/archinternmed.2010.355
Free access of the article is available: JAMA (Algorithm and Charts are available in side tabs)
PDF Version: (http://www.crebp.net.au/wp-content/uploads/2014/06/Feasibility-study-of-a-systematic-approach.pdf)
Deprescribing Informational Literature
Palliative Care Network of Wisconsin (PCNOW) Fast Facts and Concepts
Fast Facts are developed to provide concise, practical, peer-reviewed and evidence-based summaries on key palliative care topics. These are useful for clinicians and trainees caring for patients facing serious illness. Fast Fact #321 provides a general overview of deprescribing. Topics included in this Fast Fact are potentially inappropriate medications at the end of life, barriers to deprescribing, deprescribing framework and the process of deprescribing. Four other Fast Facts (#236, 258, 278, and 322) provide recommendations for managing specific topics at end of life, including if/how to treat a venous thromboembolism in advanced cancer, diabetes management, warfarin and palliative care, and statins.
● Resources:
1. Fast Facts #236 (Pharmacologic Treatment of Acute VTE Advanced Cancer)
2. Fast Facts #258 (Diabetes Management at the End of Life)https://www.mypcnow.org/blank-agxj1
3. Fast Facts #278 (Warfarin and Palliative Care)https://www.mypcnow.org/blank-defio
4. Fast Facts #321 (Deprescribing)https://www.mypcnow.org/copy-of-fast-fact-320
5. Fast Facts #322 (Discontinuation of Statins at End of Life)https://www.mypcnow.org/copy-of-fast-fact-321
Ashton Manual for Deprescribing Benzodiazepines In this manual, Professor Ashton provides information on why patients should come off of benzodiazepines after long-term use as well as steps to take before starting the withdrawal process. Chapter I describes the benefits of deprescribing benzodiazepines to avoid the unwanted side effects such as poor memory and cognition, emotional blunting, depression and increasing anxiety. Chapter II provides guidance for slowly tapering or switching from short- to long-acting benzodiazepines and designing an individualized schedule with instructions on tapering doses in weekly intervals. Chapter III describes acute and protracted benzodiazepine withdrawal symptoms.