key: cord-0868220-7d43rpfo authors: Bergman-Evans, Brenda title: A nurse practitioner led protocol to address polypharmacy in long-term care date: 2020-07-24 journal: Geriatr Nurs DOI: 10.1016/j.gerinurse.2020.07.002 sha: c0c87c66ea15fca675ca13ad97d98834d8407d3f doc_id: 868220 cord_uid: 7d43rpfo Polypharmacy is common in long term care facilities and frequently associated with poor outcomes. This study sought to determine if a medication management protocol completed at four month intervals by nurse practitioners (NP) could impact polypharmacy and administration times for long term care residents. The data was collected as part of a Centers for Medicare and Medicaid Services (CMS) “Initiative to Reduce Avoidable Hospitalization among Nursing Facility Residents” grant. Residents were recruited from participating long-term care facilities. NP completed a medication management protocol on admission to the program and at subsequent 4-month intervals or with an acute change in condition. A total of 2442 non-duplicated individuals were seen for at least 1 visit. Although the protocol did not result in a reduction of regularly scheduled medications, the number of scheduled medication administration times did significantly decrease. NP polypharmacy assessments and recommendations are important but were insufficient to decrease the medication burden. Introduction "Less is more," and "Too much of a good thing" are well known life quotes that can also be associated with the challenge of polypharmacy for older adults. As both age and the number of chronic diseases increase so often does the list of prescribed medications. International research has validated the phenomenon to be especially troublesome for older adults residing in nursing homes. 1 Strong associations with negative clinical consequences have also been noted for polypharmacy including inappropriate prescribing and medications 1,2 as well as medications that are not clinically indicated or are no longer affective. 3 Although polypharmacy often refers to a quantity, it can also be qualitatively defined as using multiple drugs or more than are medically necessary. 1, 5 Documented range definitions from five 4 to nine or more are common 5À7 Although the definitions may vary the outcomes are similar. In a systematic review of 48 studies, researchers noted that the total number of medications (polypharmacy) was consistently found to be the main driver for the phenomenon of inappropriate prescribing. 2 It is also associated with increased all-cause and potentially avoidable hospitalizations. 8, 9 The challenges of therapeutics in long term care is complicated by polypharmacy and the associated factors of adverse drug interactions, potentially inappropriate medications, and therapeutic duplication. 6 ,10À14, 37 Frailty, physiological changes of aging, and disease burden result in increased vulnerability and jeopardy. 6, 15 Aggressive medical management of co-morbidities and multiple providers add to the complexity of care in this setting. 16 The World Health Organization (WHO) defines an adverse drug reaction (ADR) as a response to a medicine which is noxious and unintended, and which occurs at doses normally used in man. 17 The use of 9 or more medications has been positively correlated with ADRs in older adult in nursing homes. 12 Polypharmacy has also been associated with an increased prevalence of drug-drug interactions and a worsening of cognitive function for residents of long term care. 18 The prevalence of potentially inappropriate medications has been noted in more than one in five nursing home residents. 19 Nieves-Perez and colleagues 20 found the number of prescribed and potentially inappropriate medications to be directly correlated. Potentially inappropriate prescriptions have also been found to increase the risk of preventable medications associated hospital admissions 21 Polypharmacy affects not only the resident but also the staff processes in long term care facilities. Thomson and colleagues 21 found that time needed for the medication administration process in LTC was significant and increased for nurses unfamiliar with residents. The realities of polypharmacy and staffing challenges may make completing medication passes in the scheduled time periods nearly impossible. The need to decrease the medication burden in long term care is well accepted. However, the lack of effective interventions to improve the management of medications in the situation has been a reality. 22 In a systematic review of 21 studies related to inappropriate Geriatric Nursing 000 (2020) 1À6 Geriatric Nursing journal homepage: www.gnjournal.com medication, researchers concluded that the high prevalence of inappropriate medication use supports the importance for monitoring and that monitoring is endorsed by health professionals. 23 The importance of regular medication review and further inquiry into the risk-to-benefit ratio of prescribing in long term care have been suggested by researchers exploring the association between polypharmacy and complex medication regimens and hospitalization. 24 Prescriber recommendations based on interviews and medications reviews by consulting pharmacy recommendations have been found related to significant alterations in therapy including polypharmacy reductions and decreased high risk medications. 25 Safe discontinuation of medication(s) requires a thorough plan. 50 Key steps to rational discontinuation plan include the establishing the indication for the action, identification and prioritization of meds to be stopped, and creation of a plan that includes communication and coordination with other providers and the means to monitor effects. 51 Researchers combined the principles of geriatric and palliative care medicine in the creation and use of a step-wise geriatricpalliative algorithm to successfully address polypharmacy. 52 Their interdisciplinary team were able to reduce an average of 2.8 drugs, costs, and acute care transfers without significant adverse effects. 52 Haque and Zakia 55 demonstrated both the utility of a tool protocol and the value of an interdisciplinary team in a year long study that had positive outcomes including reducing antipsychotic use. The ARMOR (Assess, Review, Minimize, Optimize, Reassess) protocol was augmented with an interdisciplinary team that included director of nursing, a nurse manager, a social worker, an activity director, and the medical director. Noncore members included rehabilitation therapists, consultant pharmacists, dietitians, and certified nurse aides. Nurse practitioners effectively meet the complex health care needs of older adults in long term care facilities. NPs acting as primary care providers in long-term care facilities have been shown to achieve positive outcomes including improved chronic disease care and to promote functional health and decrease polypharmacy, falls, restraint use, and transfers. 26À29 The purpose of this descriptive study was to determine if a medication management protocol completed at four-month intervals by nurse practitioners would decrease polypharmacy and administration times for long term care residents. Institutional Review Board approval was obtained for secondary analysis of preserved medication management data collected from the "Enhanced Care and Coordination Project" from the Centers for Medicare & Medicaid Services' (CMS): Initiative to Reduce Avoidable Hospitalization among Nursing Facility Residents, Grant#1E1CMS331085À03À01. Sample: Fifteen (15) participating long-term care facilities were recruited to participate in the 4-year study. Inclusion criteria was determined by the CMS grant: 1) dual eligible Medicare-Medicaid resident; 2) living in the participating facility for > 101 days; 3) not expected to return home; 4) not expected to transition to facility providing less support. The CMS grant protocol allowed for an "opt out only" enrollment process. Residents who met the inclusion criteria were advised of the program, the process, and the opt out option. Written informed consent was not required because it was a "benefit" program with no costs and no identified risks. Specified site facilitators provided the project director with a list of eligible residents each month. Letters of introduction/invitation to participate were provided to the resident/family/Power of Attorney and included the following information: Participation in the program did not require a change in health care provider, health plan enrollment, nor existing Medicare/Medicaid benefits. Benefits of the program included regular and emergent nurse practitioner care, collaboration, medication management, and dental hygienist care. The process to opt out of the program initially or at any time during the grant period. Study Protocol. Five nurse practitioners provided routine and emergent care to study participants. Routine care included completion of the Medication Outcome Monitor (MOM), 32,47 a medication management protocol. The schedule started with admission to the program (program initiation or 101 days in the facility) and was repeated at 4-month intervals or with an acute change in condition The MOM 32,47 is an evidencebased guideline designed to improve medication oversight and management for older adults living in long term care facilities. The MOM 32, 47 was completed using data from the current Medication Administration Record (MAR), resident chart, Minimum Data Set (MDS), and history and physical examination. The polypharmacy section of the Medication Outcome Monitor (MOM) 32,47 is used to record number of medications and medication administration times. The CMS grant required that the participating resident and primary care provider/medical director relationship not be interrupted by the study interventions. Therefore, a collaborative/consultant model was used for sharing information/suggestions between the NP and the primary care providers/medical directors for decisions regarding medication/treatment changes. Recommendations were communicated via the primary provider's preferred communication (fax or phone call). The data collection period began in February of 2013 and ended in September of 2016. At the conclusion of the grant, data from the Medication Outcome Monitor (MOM) 32,47 was de-identified and preserved for secondary analysis. Data was securely preserved on an encrypted disk. SPSS 25 was utilized for data analysis. Descriptive and inferential statistics were generated to describe number of reviews, polypharmacy, administration schedules, and recommendations. Nurse Practitioner Medication Reviews: The MOM 32,47 was completed a total of 10,448 times with a range of 1 to 13 visits on 2442 individual study participants seen for at least one visit. Only 4 individuals (0.16%) opted out of participation at any time. The nurse practitioners collaborated with 364 primary providers/medical directors. Fourteen (14) facilities enrolled study participants from initiation (Spring, 2013) to completion of the grant period (September 2016). By mutual agreement, 1 facility participated only from the Spring of 2013 until September of 2014: 161 residents (6.6% total enrollees) complete 480 visits (4.6% total visits) with a range 1À5 visits. Table 1 presents the NP visits and completed MOM. 32, 47 The years represent individual resident participation rather than calendar grant years. Residents were admitted to the program over the life of the grant. When residents met the inclusion criteria the initial visit was completed and they received revisits every 4 months as long as they remained eligible, did not opt out, and were in a participating facility. Years 1, 2, 3, and 4 in Tables 1, 2, and 3 represent MOM 32,47 completions for the individual participant regardless of whether they were admitted in the first or final years of the grant. Table 1 presents the NP visits and completed MOM. 32, 47 Polypharmacy The mean number of scheduled medications is presented in Tables 2. The initial average of 11.23 showed a slight upward trend until year four. The trends were not statistically significant. Administration Times: Table 3 presents the number of scheduled administration times. The mean reduction was 0.47 visits over the study period. The ANOVA between groups resulted in a mean square of 1.153, an F value of 3.587, and a significance of 0.006. NP Change Recommendations: As a result of the completion of the MOM 32,47 and/or with emergent visits, the NPs recorded recommendations that are presented in Table 4 . Rationale for change recommendations are presented in Table 5 . Slightly less than 20% of the time (1959/10,448 times), a recommendation was communicated. Of the recorded recommendations, two-thirds were for no change. For the decreased dose/and or medication, the suggestions were accepted 59.3% of the time. As the US Population has increased, the number of Individuals needing long term care has risen. 33 The parallel increase of age and medication usage often results in polypharmacy especially for older adults residing in long term care facilities. Of the 2442 unique individuals admitted to this study over the 48 month period, nine were seen at four-month intervals for 13 visits. Nearly one in three (29%) of the sample were seen only once. Because admissions continued throughout the 48 months, the exit of one facility may have contributed slightly to the decrease in participants after five visits. Additionally, there were residents that were at the end of a Medicare Part A stay and met eligibility requirements, were admitted to the program, but subsequently either went home or were dismissed to other long term care facilities for permanent residence. Polypharmacy was present throughout the course of the study and higher than previous reports in similar populations. 5,6,7 The high percentage of residents that were seen only one or two times may have affected the impact of the intervention since developing relationships with residents, staff, and providers and understanding the context and history of complex medication regimens requires time and building of relationships. The polypharmacy statistics do not take into consideration the medications that were decreased in dose but not discontinued. The impact of multiple providers as well as the addition of medications from after hours or emergent on call providers not familiar with long term care work or individual plans of care could have impacted results. Patient and family preferences also impact changes in medication therapy in long term care. For this study, NP use of the consultation role rather than working to the top of license in the primary provider role may have contributed to the failure to decrease polypharmacy. Pharmacists have encountered barriers to communication and mixed responses to the consulting pharmacist recommendations for medication therapy management. 38, 39 Administration times Decreasing the number of times that medications are administered is a positive outcome for all stakeholders. 21 Nurses in long term care facilities are expected to pass. apply, and/or insert medications on 15À30 residents and complete the task within 1 hour of the scheduled time. With interruptions inherent in the workplace and the complexity and vulnerability of the residents, the expectation can be difficult to meet. Success at decreasing the number of medication passes by almost a half (0.47) is significant. This task reduction has the potential to allow nurses greater time to focus on maintaining and promoting quality care. For residents, leisure and quality of life activities are not interrupted. This is also beneficial for decreasing cost of personal protective equipment. By decreasing the number of med passes, risks of COVID-19 transmissions and cost of personal protective equipment also are reduced. 59 During initial contacts, the NPs sought to acquaint both providers and residents with the program and to acquaint themselves with the plan of care. This, in addition to the number of individual providers and residents seen only one or two times may have contributed to the high number of "No Change" recordings. Receipt of a response for 2 out of 3 of the actual recommendations was consistent with past pharmacy studies. 38, 39 The phenomenon "alert fatigue" may have impacted responses to the NP recommendations in our study and to suggestions for medication changes in general. The lack of response for a third of the recommendations may have been related to the volume of communication and paperwork that primary providers receive associated with caring for older adults in long term care. Clinicians have been found to be less likely to accept alerts as they receive more of them, particularly more repeated alerts. 36 After no change, the primary recommendation was to decrease the number or dose. Although the outcome of number of medications was not affected, the findings supports the potential for identifying medications that could be decreased. Suggestions that one drug be decreased or discontinued and a different drug added or increased is consistent with the work of Kroenke and Pinholt that found that discontinuation of prescribed medication is the least likely recommendation to be followed by physicians . 34 Recommendations that suggested increasing or adding medications may have been related to the complex nature of this population as well as that this response category included both routine and emergent conditions such as infections. The relatively few lab updates needed could be explained by the work of the pharmacy reviews. For providers, review of the resident's total program of care, including medications and treatments is an expectation of the mandated 60 day periodic review process 35 Medication reviews alone are not enough to decrease polypharmacy or affect other clinical outcomes. 1,37 A patient centered process of deprescribing directed at medication withdrawal can improve health outcomes by discontinuing one or more potentially harmful and/or unneeded medications. 48, 49 Population-specific guidelines that emphasize functional status and quality of life over more conventional disease-focused guidelines are especially needed in long term care. 40 In a review of interdisciplinary interventions, researchers found that interventions that involved PCPs and pharmacist had positive outcomes. 53 The contributions of pharmacists in ensuring quality medication management in nursing homes is significant. 57 Pharmacist review medication lists at least monthly and report any irregularities to attending physicians and director of nursing for action. 35 Ongoing and open communications between the consulting pharmacist and the provider, director of nursing, nursing staff, resident, and family have significant potential to decrease polypharmacy. 58 The value for increased efficiency and effectiveness of multidisciplinary medication reviews has been noted when the physician is in attendance. 56 Being able to clarify questions and execute recommendations are important. Nurse practitioners working in long term care have the knowledge and skill sets 30, 31 to take leading roles in this work. Additional members of interdisciplinary teams, often tailored to the specific needs of facilities and populations, include nursing, 56 social workers and administration. 54 Since nursing assistants provide most of the direct resident care in nursing homes and are often with specific residents over extended time periods, 62,63 selectively including them when major plans of care and/or medications are proposed may be beneficial. Creation of an interdisciplinary virtual medication management huddle that coincides with and augments the consulting pharmacist reviews and requirements could be of benefit and help to meet both time challenges and Coronavirus 19 Guidelines 61 related to social distancing and personal contact. Clear guidelines of member expectations and deliverables are needed. Use of standardized tools such as the Geriatric Palliative Care Algorithm 55 and the ARMOR Protocol 52 could be of benefit. Once prescribed, discontinuation of medications is often difficult. 60 Nursing and clinical staff have can have significant impact on polypharmacy. Foremost is avoiding a medication when a nonpharmacological intervention is available. They should be the initial focus for delirium 41 and behavioral and psychological symptoms with diagnosis of dementia. 42 In addition, these measures have been found to aid in decreasing falls, 43 improving psychosocial health and well-being, 44 potentially enhancing sleep, 45 and reducing pain and prn medications. 46 Although some success was made with the decrease recommendations, the lack of significant impact suggests that just as the reasons for polypharmacy are multifaceted so will efforts to address it have to be. The synergy of an inclusive interdisciplinary team, with regular and invited input from administration, providers, nurse practitioners, medical directors, consulting pharmacists, nursing, direct care staff, and support services is important. Communication and team membership need to be flexible and match the specific resident and facility profile so that improved medication management takes place. With shared goals and clear outcomes for medication management for the very frail older adults residing in long term care, decreasing polypharmacy is possible. The 5 Rights: patient, drug, dose, route, and time are as important for medication prescriptions and maintenance as for administration. Clinical consequences of polypharmacy in elderly Prevalence of potentially inappropriate medication use in older adults living in nursing homes: a systematic review Polypharmacy in the elderly: a literature review Polypharmacy: evaluating risks and deprescribing What is polypharmacy? A systematic review of definitions Physician intervention for medication reduction in a nursing home: the polypharmacy outcomes project Searching for a polypharmacy threshold associated with frailty Medications and prescribing patterns as factors associated with hospitalizations from longterm care facilities: a systematic review The association between potentially inappropriate prescribing and medication-related hospital admissions in older patients: a nested case control study Evaluation of pharmacotherapy complexity in residents of long-term care facilities: a cross-sectional descriptive study The national nursing home survey: 2004 overview Polypharmacy as a risk factor for adverse drug reactions in geriatric nursing home residents Vander Stichele R. Pharmacists' interventions for optimization of medication use in nursing homes : a systematic review Polypharmacy À Time to get beyond the numbers Potentially inappropriate medications and their use in elderly populations residing in long-term care facilities Prevalence and factors associated with polypharmacy in long-term care facilities: a systematic review Adverse Drug Reactions Database Association of polypharmacy with 1-year trajectories of cognitive and physical function in nursing home residents: results from a multicenter European study Polypharmacy and potentially inappropriate medications: a cross-sectional analysis among 451 nursing homes in France Inappropriate medication use among institutionalized older adults at nursing homes in Puerto Rico Nursing time devoted to medication administration in long-term care: clinical, safety, and resource implications Polypharmacy in nursing home residents: what is the way forward? Prevalence of inappropriate medication use in residential long-term care facilities for the elderly: a systematic review Polypharmacy and medication regimen complexity as risk factors for hospitalization among residents of long-term care facilities: a prospective cohort study Comprehensive medication reviews in longterm care facilities: history of process implementation and 2015 results Care of nursing home residents by advanced practice nurses A review of the literature Affiliations expand a mixed methods quality improvement study to implement nurse practitioner roles and improve care for residents in long-term care facilities Effects of substituting nurse practitioners, physician assistants or nurses for physicians concerning healthcare for the ageing population: a systematic literature review Opportunities for advance practice nurses in the nursing facility Utilization of nurse practitioners in long-term care: findings and implications of a national survey Value-added outcomes: the use of advanced practice nurses in long-term care facilities Improving medication management for older adults residing in long Àterm care facilities Long-term care statistics you need to know Reducing polypharmacy in the elderly: a controlled trial of physician feedback CMS State Operations Manual Appendix PP -Guidance to Surveyors for Long Term Care Facilities, revision 173 Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system American geriatrics society 2019 updated ags beers criteria Ò for potentially inappropriate medication use in older adults Impact of pharmacist identification of medicationrelated problems in a nontraditional long-term care pharmacy Physicians' preferences for communication of pharmacist-provided medication therapy management in community pharmacy Screening and preventive services for older adults Responding to ten common delirium misconceptions with best evidence: an educational review for clinicians Difficult behaviors in long-term care patients with dementia Effectiveness of non-pharmacological interventions to prevent falls in older people: a systematic overview. The SENATOR project ONTOP Series St€ arkung der psychosozialen Gesundheit von Bewohnerinnen und Bewohnern der station€ aren Langzeitpflege: systematische € Ubersicht zu Interventionen der Pr€ avention und Gesundheitsf€ orderung [Improving psychosocial health of nursing home residents: a systematic review of interventions for prevention A systematic review of non-pharmacological interventions to improve nighttime sleep among residents of long-term care settings Non-pharmacological approaches to pain management in residential aged care: a pre-post-test study Improving medication management for older adult clients residing in long term care facilities Tips for deprescribing in the nursing home A concept analysis of deprescribing medications in older people American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Patient-centered care for older adults with multiple chronic conditions: a stepwise approach from the American geriatrics society: american geriatrics society expert panel on the care of older adults with multimorbidity Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use process The war against polypharmacy: a new costeffective geriatric-palliative approach for improving drug therapy in disabled elderly people Systematic review of interdisciplinary interventions in nursing homes Implementing psychopharmacology rounds in a nursing facility to improve antipsychotic usage Assessing the impact of an interdisciplinary team approach using the armor protocol on the rate of psychotropic medications and other quality indicators in long-term care facilities A clinico-ethical framework for multidisciplinary review of medication in nursing homes Pharmacist services in nursing homes: a systematic review and meta-analysis The medication regimen review: building rapport with the consultant pharmacist Guidance for infection control and prevention of coronavirus 2019 (COVID-19) in nursing homes (revised) Prescriber barriers and enablers to minimizing potentially inappropriate medications in adults: a systematic review and thematic synthesis Responding to coronavirus (COVID-19) in nursing homes. Considerations for the public health response to COVID-19 in nursing homes The associations between staffing hours and quality of care indicators in long-term care Meaning making in long-term care: what do certified nursing assistants think?