Inappropriate prescribing, which includes polypharmacy (the use of multiple medications by an individual), using the wrong medications, or too few medications is especially common in post-acute and long-term care facilities. Patients transitioning after acute care stays and residents of long-term care often have multiple prescribers, new or evolving diagnoses, and chronic conditions that can flare if not managed properly. There are also regulatory issues and concerns that can influence prescribing patterns anddistort how medications are used and diagnoses are made.
Studies show the typical nursing home resident takes an average ofseven medications, which significantly increases the likelihood of potential adverse drug events. Residents and their families rely on the care team to ensure the safe delivery of the right medications, dosages, and frequency.
For years, however, medication management in the long-term care setting has been a challenge. Medication overuse, the most common scenario, often results from the following:
Multiple specialists prescribing medications that may interact with medications prescribed by other physicians.
Introduction of medications to treat side effects caused by other medications, which can quickly spiral out of control.
Different sources of truth for the patient’s active medication list (i.e. hospital list vs outpatient list).
Difficulty quantifying the risks of a particular medication and reducing those risks.
Challenges shaping the medication regimen to meet the specific needs of a patient, especially for frail patients and those with multiple chronic illnesses.
All of these scenarios put patient safety at risk and burden staff with lengthy medication reconciliation. Adding to an already complex medication mix is the COVID-19 pandemic, which has overwhelmed staff and consumed precious time. Not only is there less time and fewer staff to reconcile and administer medications, but doing so requires added time with the patient, increasing the chances of potential COVID-19 exposure.
Deprescribing is a solution that can be adopted across any long-term care setting to help reduce the burden and risk associated with polypharmacy. In essence, deprescribing is the reduction or elimination of medications that may no longer be appropriate for the patient or could cause potential harm. It requires digging deep into a patient’s medication list to determine:
The risk of side effects from each medication and how to mitigate the risks.
Whether the medication aligns with a diagnosis on the patient’s problem list (i.e should it be on the active medication list).
If a medication is causing a side effect for which another medication has been prescribed. And, can that initial medication be changed or eliminated along with the second medication?
Patient-specific risks of adverse drug events due to kidney and liver function, other factors influencing drug metabolism and sensitivity, and the dosages and medications for each patient.
If there are medications that may have interactions with other medicines that were inadvertently overlooked by the prescribing physician.
Given the time constraints post-acute and long-term care professionals face, what’s the best strategy for deprescribing? Most approaches rely on using the Beers list,or similar tools to identify medications that are high risk for seniors,in combination with other practical approaches to eliminating unnecessary medications. For example, a quick call to a community pharmacy can be an important step in medication reconciliation and save staff time.
The addition of AI technology embedded with an EMR can address two key gaps in safe medication management. First, these tools can identify and prioritize high medication-related risks. Second, they can identify patient-specific risks, provide personalized risk assessments, and give staff insight into which medications to deprescribe.
Developing a comprehensive, streamlined approach to deprescribing is necessary for both the safety of the patients and to ease the workload of staff. This is best achieved using a combination of tools and leveraging technology specifically designed to help improve patient safety and medication management.
Dr. Mike Cantor Dr. Cantor is a senior physician, executive, and consultant with success in leading Geriatrics, Medicare, Medicaid, and commercial medical management operations, product strategy/design, and business development. His industry experience includes leadership roles in payers, private equity-backed home health and post-acute benefits management, and physician networks.
Dr. Mark Yurkofsky Dr. Yurkofsky is an expert in the management of post-acute and long-term care with over 25 years of experience practicing in post-acute and long-term care facilities, and most of that time as a medical director and leader in long-term care and post-acute care facilities. He is a Certified Medical Director for post-acute and long-term care facilities and is on the faculty of Harvard Medical School.