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Presented at Optimizing Medications workshop in Vancouver by Christine Gemeinhardt
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KinVillage Polypharmacy Reduction Pilot Project
“The Jumpstart”
Christine Gemeinhardt, MD, MSc, CCFP
Medical Coordinator
January 16, 2014
Disclosure Statement
No conflict of interest
Project Team
• Christine Gemeinhardt, Medical Coordinator
• Edwin Lee, Pharmacist
• Kelly Marshall, RN, Clinical Practice Leader
• Cynthia Langenberg, Director of Health Services
• And all other participating care staff
Results January 2013 – June 2013
Time 0
Total # meds/99 residents
897
Meds/resident
9.0
6 months
Total # meds/99 residents
659
Meds/resident
6.7
Change in Meds - Pilot Project
2.3 per resident
26%
Time to backtrack……….
What made this project possible?
(Nursing homes are heterogeneous)
KinVillage demographics:
Tsawwassen, S Delta
Contracted site
Fraser Health Authority
99 residents - 13 Special Care Unit
The Team
Med Review Team
Medical
Pharmacist
Clinical Practice
Leader
Director, RNs, LPNs
Project Medication
Reviews
“Jumpstarting”
Intensive Work:
33 residents/week
4-5 minutes/resident
2 ½ hours per session
Weekly sessions X3
99 residents
Pre-requisites for Rapid Fire Med Reviews!
“Jumpstart” Med Review Timeline
Start 0
3 months
6 months
Process – Pharmacist Medication Count
Time 0
January 2013
6 months
June 2013
Post project follow up
12 months
January 2014
Our Pharmacist, Our Hero
KinVillage Polypharmacy Reduction Pilot Project
Basic premises
Frail residents are at the end
of their life cycle
Focus on quality of life,
not cure or longevity
Residents receive too
much medication
“Medication focus” wastes
valuable nursing time
Earlier initiatives that made KV ripe for a polypharmacy reduction project
2011 Hospital Transfer Reduction Project
2012 Education on the palliative paradigm
Use of FH Protocol for the Actively Dying
2012 KV Physician Agreement
Change in physician coverage demographics
Unscheduled hospital transfers from 10% to 4%
meds & transfers
Number of different MRPs from 23 to 14, improved engagement
Number of residents under Med Coordinator
Attrition of community physicians
Aging and semi-
retirement
Travel time, inconvenience,
too few residents
Lack of interest,
other areas of commitment
Physician Agreement
Attrition
Unable to accept or
meet requirements
Physician Agreement
Engaged
Accept
KinVillage Physician Agreement
Dear Dr _______________________, Date: __________________
Your patient, _________________________________, is now a resident of KinVillage -
Complex Residential Care.
Each resident at KinVillage has a Main Responsible Physician (MRP). The MRP is asked to
fulfill the following duties:
1. Be available to reconcile the resident’s medications the day of admission
2. Visit the resident within 2 weeks of admission
3. Visit the resident routinely on a quarterly basis, review with nursing staff, and write
legible chart notes 4. Provide timely onsite assessment and care when the status of the resident changes
5. Provide timely onsite assessment prior to initiating transfer to hospital and communicate
with the Emergency Physician
6. Meet with the resident’s representative(s) in person to complete the MOST (Fraser Health
Medical Orders for Scope of Treatment) within a week of admission. 7. Meet with the resident’s representative(s) during the end-of-life phase
8. Attend the resident during the end-of-life phase
9. Attend annual or biannual multidisciplinary care conferences.
10. Provide a replacement MRP when unavailable
In addition to the care provided by the MRP, all KinVillage residents are reviewed by the Medical Coordinator (MC). The MC is a physician who has particular interest and additional
training and experience in complex residential care. The MC has been engaged by KinVillage
and the Fraser Health Authority. The MC provides oversight and makes recommendations for
resident medical care. This oversight can be provided at the discretion of the care staff, Director
of Health Services, and MC at any time, not only during emergencies. The MC will strive to communicate with the MRP when attending to a resident.
Please choose one of the following:
1. I am able to fulfill the MRP duties and wish to be MRP. 2. Dr _________________________ has consented to be MRP in my place.
3. I would like to be MRP but request that the MC assist with care conferences and
medication reviews.
4. I would like to request that the MC assume MRP for my patient.
Also, I would like to accept orphaned residents.
Signature:___________________________________________Date:________________
Preparation = Medication-Specific Information
as it relates to the resident
BP
pain
edema sleep
behaviour
How?
A highly individualized process with resident-centered
decision-making
Beers
Gallagher Other published guidelines
Guiding Questions
Medication Decision-Making
Goals?
Frailty?
Prognosis?
Strategy: Radical Pruning
(Meds most often stopped)
• Statins
• Osteoporosis
• Calcium
• Vitamins
• Unused prns
Strategy: Reducing and Streamlining
Examples
• Antihypertensives 3 2 1
• Diabetic meds dose
The Psychotropic Cocktail aka “Witch’s Brew”
Analgesics
Streamlining of
Analgesics
Stop acetominophen
if requiring opioid
Convert to
long-acting
Convert to patch
Strategy: Simplification
Eg. Constipation
Switch from
sennosides+lactulose+supps+enemas
to
PEG
3 1
Kin Village Medication Review
Polypharmacy Reduction Initiative
Re: Date:
Dear Dr Today we reviewed your resident’s medication profile using current polypharmacy reduction strategies and clinical assessment. We recommend discontinuing medications
that are deemed harmful, unnecessary, or of dubious benefit in the frail, elderly residential population. We recommend reviewing dosages of medications and possibly decreasing them. We recommend removing unused prn medications from the medication list. We are also attempting to simplify the resident’s drug regimen.
Recommendations
It is a pleasure working with you in caring for this resident. We welcome your comments
and feedback. Yours truly,
Christine Gemeinhardt, Medical Coordinator, 604-317-8721 Edwin Lee, Pharmacist, 604-943-9341 Nadine Brown, RN, Clinical Practice Leader, 604-943-0155
Complex Communication
Levels:
Med Review Team to nursing staff
Nursing to family
Med Coordinator to family
Med Coordinator to community GP
Nurse to community GP
Community GP to pharmacist
Nurse to pharmacist
Etc
Challenges with “Jumpstart”
• Time commitment
• Nursing routine disrupted
• Orders generated
• Nursing staff buy-in
• Community physician buy-in
• Consultant visits
• Sustainability YES!
Sustainability - results # meds/resident
Start
9.0
6.7
6 mo
12 mo
6.2
Long Term Sustainability
New resident review 1 week
Care conference 2
months
(Informal review)
6 month formal Team
review
(informal review)