3 Steps to Medication Optimization

More than 90% of long-term care residents take 5 or more medications, and 65% take 10 or more. The risk of adverse events from medications increases after five medications, and there are an estimated two million or more adverse drug events per year, with 1 in 7 residents being hospitalized because of them.

Medication optimization is an effective way to decrease polypharmacy and adverse drug events while improving health outcomes in long-term care. While successful medication optimization requires the cooperation of the team and must be customized for the capabilities, staffing, and makeup of the residents in each building, there are a few key steps to implementing a sustainable approach that has the commitment of the entire facility. It’s important to note that these efforts must be heightened during transitions of care (admission and discharge), change in status, or at the patient’s or family’s request.

Step 1: Start with Reconciliation

Medication reconciliation is an essential step and should occur at any point when there is a transition of care or a change in orders but also at admission, discharge, during a hospital stay or ER visit, and when an outside provider visits. The activities should involve a few key steps:

? Comparing active orders versus documentation provided

? Looking for discrepancies and potential explanations

? Looking for abnormalities such as dose irregularities or inappropriate diagnosis associated with medications in the regimen

? Identifying opportunities for medication optimization, including eliminating duplicates, preventing or stopping a prescribing cascade, and eliminating unnecessary medications

The team should be alert to medications that are more commonly associated with adverse events and other issues. For instance, anti-infectives are commonly prescribed and associated with antimicrobial resistance and C. difficile infections. Practicing antibiotic stewardship, including ensuring that diagnostic criteria for the use of these drugs are met and that orders contain a limited duration of treatment, will help make sure these medications are being used appropriately.

Caroline Garvey , PharmD, BCGP, manager of clinical operations at PharMerica, stressed that medication optimization doesn’t mean never prescribing high-risk medications like antipsychotics. Instead, she said,” We need to make sure they’re being prescribed and monitored appropriately. We need to ensure we have the behaviors and psychological symptoms that meet the criteria for these medications, and we need to monitor for side effects and opportunities for dose reductions.”

Step 2: Maximize Medication Reviews

Monthly medication regimen reviews are required by regulation for patients in skilled nursing facilities; however, completing additional routine interdisciplinary medication optimization reviews can be an important contributor to successful outcomes.

This process generally includes:

? Collaboration between the DON, resident, family, pharmacist, and prescriber

? Communication (via letter) to families and/or residents to review the process ahead of time. Nancy Tuders , RN, GERO-BC, IP-BC, CDONA, FACDONA, assistant director of education at NADONA LTC , said it is important to involve them in the process and help them understand how this will benefit residents.

? Prioritizing residents/units with highest number of medications as well as diagnoses linked to high-risk medications

In addition to residents/families and pharmacists, reviews may involve team members such as the prescriber, DON, CNAs, dieticians, physical and other therapy professionals, and social workers. Garvey observed, “The intent of the review is to evaluate all medications and supplements taken by an individual resident, with the aim of reducing dosages, discontinuing unnecessary or non-required drugs, and reducing costs.”

Step 3: Keep the Process Going

Medication optimization isn’t a one-and-done process. However, a few steps can help your program get on the road and moving steadily ahead:

? Formalize roles with systems to capture necessary information and data ? Consistently hold monthly collaborative grand rounds

? Enhance actionable and automated reporting of overall and subcategories of medication reporting for prescribers/clinicians and medical directors

? Assess the impact of efforts on other metrics such as hospitalization rates, falls, and quality measures

? Enable and encourage effective and prompt collaboration between team players, engaging everyone’s expertise and knowledge

? Hold team training that includes changes to Section N: Medications of the Minimum Data Set

While medication optimization may take some out of their comfort zones, the results will likely make them allies. At the same time, Tuders cited studies showing that “many older adults say that they want to cut back on taking all these multiple medications, and they really trust their pharmacist and their physician.” She added, “About 82% of Americans between the ages of 50 and 80 take one or more prescription medications, and 80% of them want to explore reducing the number of medications they’re on if their doctor would allow it.”

Tuders emphasized, “It’s going to take a while to pick up steam on your medication optimization program, but pick a goal of what you want to start with and get moving. Remember to go slow and steady. We can optimize the medications ideally one at a time. That is the way to start.”