When elderly patients are transferred from a hospital to a nursing home, they often arrive with 10 or more prescriptions—a challenging number to manage even for patients who aren’t frail.
Frail elders are particularly susceptible to the harms of medication overload such as adverse drug events, cognitive impairment, falls, and hospitalization. The Mother Cabrini Health Foundation awarded United Hospital Fund’s Quality Institute a grant at the end of 2021 in support of a one-year project to address problems associated with the use of multiple medications, or polypharmacy, for long-term residents of nursing homes. Important additional support was received from the TD Charitable Foundation.
Earlier this year, UHF created a Polypharmacy Learning Collaborative with six New York skilled nursing facilities (SNFs) to design and implement ways to better monitor and assess medication regimens and prescribing practices and consider the use of deprescribing, the process of medication withdrawal, supervised by a health care professional, with the goal of managing polypharmacy and improving outcomes. On May 10, the collaborative held its second learning session with the members to hear from subject matter experts, network, and learn from each other’s experiences in managing their residents’ medications.
Several SNF participants in attendance shared that virtually every patient who is admitted from a hospital arrives with a prescription for a proton pump inhibitor (PPI), a treatment for acid reflux that is one of the most prescribed drugs in the world. “PPI prescriptions seem automatic,” said a representative of Mary Manning Walsh Home in Manhattan. A staff member of Jamaica Hospital Nursing Home in Queens said that 75 to 80 percent of their new residents admitted from hospitals are on a PPI. “Every month our pharmacy is reporting to us that we need to look at PPI prescriptions,” she said.
The attendees agreed that when a new patient is first evaluated, it is a good opportunity to reset medications and reduce or eliminate those that are not necessary or optimized. In many cases, lifestyle and dietary changes can replace medications.
An important component of the meeting was a presentation on how to communicate with clinicians, patients, and their families when deprescribing medications, presented by Jennifer Pruskowski, Pharm D, Associate Director for Education and Evaluation at the Veterans Affairs Pittsburgh Geriatric Research Education and Clinical Center. Dr. Pruskowski emphasized that assessing and restructuring a regimen of medicines is only half the process of managing a patient’s prescriptions. Communicating with residents and families the reasons for the changes, and what to expect as medications are withdrawn, is just as important.
“Deprescribing is a process,” she said, and recommended never making more than three medication changes at a time to make the process easier to understand for patients and families.
Dr. Pruskowski broke the deprescribing process into four parts:
1) Provider engagement
2) Resident, family/caregiver engagement
3) Non-pharmaceutical interventions
4) How adverse drug withdrawal events will be handled
She noted that stopping a medication may not feel helpful to family members who have already been told by a hospital clinician that the drug is necessary. “It’s important to still offer something to the families. Think about what non-pharmaceutical interventions you could offer instead.”
The learning session attendees also heard the details of a real-life intervention from Thiruvinvamalai Dharmarajan, MD, vice chairman, Department of Medicine, clinical director, Division of Geriatrics and program director, Geriatric Medicine Fellowship Program at Montefiore Medical Center. He described a study by his team published in the Journal of the American Medical Directors Association, Deprescribing as a Clinical Improvement Focus.
During the six-month study, clinicians attempted deprescribing during at least one encounter daily at two long-term care facilities and an outpatient geriatrics clinic in the Bronx and identified those factors that influenced the process. The team ultimately deprescribed an average of 1.4 medicines per patient encounter, with the highest success in discontinuing prescriptions for antihistamines, analgesics, PPIs, and statins. They had a lower success rate ending the use of anti-psychotics, thyroid medications, and antidepressants.
With the support of clinical faculty and UHF staff, the nursing homes in the Learning Collaborative will participate in two more learning sessions, receive coaching to develop and implement their interventions, focus on medication categories most relevant to their resident population, and collect data to assess the impact of their interventions.
The six participating nursing homes are:
• Archcare at Mary Manning Walsh Home
• Cobble Hill Health Center
• Eger Health Care and Rehabilitation Center
• Gurwin Jewish Nursing and Rehabilitation Center
• The Hebrew Home at Riverdale
• Jamaica Hospital Nursing Home
The Polypharmacy Learning Collaborative builds on another UHF project supported by Mother Cabrini Health Foundation, SNF Learning Collaborative. At the Polypharmacy Collaborative’s conclusion, UHF will publish its findings, together with tools and recommendations for other organizations seeking to develop their own deprescribing initiatives. TD Charitable Foundation is also supporting the project and dissemination efforts spread learning and best practices.