Medication Safety during Transitions of Care: Clinical Implications

Section 2.6: Tools to Improve Transitions of Care Processes

This section is divided into 5 Parts:

• Part 2.6.1: Care Transitions Tools

• Part 2.6.2: Medication Reconciliation Tools

• Part 2.6.3: Medication Management Tools

• Part 2.6.4: Deprescribing Tools

• Part 2.6.5: Risk Screening Tools

Part 2.6.1: Care Transitions Tools National Transitions of Care Coalition (NTCC)

The National Transitions of Care Coalition (NTCC) acknowledges the complexity of transitions of

care. Poorly-defined responsibilities and ineffective patient hand-offs between care settings can

poorly impact care delivery during this vulnerable time. Poor outcomes may include: wrong

treatment, delay in diagnosis, severe adverse events, patient complaints, increased healthcare

costs and increased length of stay.

NTOCC created many tools for healthcare professionals to use to improve transitions of care

within any care setting.

• Patient medication list o Helps patients and caregivers keep providers informed of most up-to-date

medication list

• Patient Bill of Rights during transitions of care

o Outlines information and services patients deserve

• “Taking Care of my Healthcare” consumer tool

o Guides patients and caregivers on what kind of information and questions to ask providers

• Informational slide deck and brochure for consumers

o Summarizes what transitions of care is and what NTCC tools are available • Implementation plan

o Outlines the concepts, process and "how to" on implementing and evaluating a Transitions of Care plan

• Transitions of care checklist o Helps enhance communication among health care providers, between care

settings, and between clinicians and clients/caregivers

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• Importance of health information technology (HIT)

o Identifies HIT problems and considerations to improve overall transitions of

care • Medication reconciliation essential elements

o Outlines important considerations when implementing a medication reconciliation program to reduce medication errors

• Policy paper and Issue Briefs o Details vision of NTCC to improve transitions of care and guidance for improving

transition performance

• Cultural competency paper o provides information about culture, cultural competence, and strategies and

resources to enhance professionals’ capacity to deliver culturally competent services

Some of these practical tools are also available in Spanish or French translations.

• Resource: This link directs you to the NTCC tools and resources available for download:

http://ntocc.org/WhoWeServe/HealthCareProfessionals.aspx

Interventions to Reduce Acute Care Transfers (INTERACT®)

Interventions to Reduce Acute Care Transfers (INTERACT®) is a quality improvement program

that includes clinical and educational tools to help post-acute care providers manage acute

change in patient conditions and prevent avoidable transfers to the hospital.

INTERACT® tools are currently available for Nursing Homes, Assisted Living, and Home Health

Care practice settings; coming soon is a version for ACOs Health Systems and Bundled Payment.

These site-specific clinical and education tools include:

• Quality improvement tools

• Communication tools

• Decision-support tools for change in condition • Advance care planning tools

• Resource: Users are required to complete a free license agreement to access these

tools. This link directs you to the INTERACT® tools available for download:

http://www.pathway-interact.com/interact-tools/

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Atlantic Quality Improvement Network (AQIN) Care Coordination Initiative Tools for Patients

Atlantic Quality Improvement Network (AQIN) Care Coordination Initiative collected numerous

helpful tools for patients and caregivers to use during transitions of care. These include:

• Personal Health Record (also available in Spanish) o Form to record health history, medical conditions, medications, allergies, and

recent hospital and doctor visits

• Medication Management Golden Rules

o Tips to understand and keep track of current medications and changes made

• Ask Me 3

o Three key questions for patients to ask providers when receiving care • Hospital Discharge Planning Golden Rules

o Tips to communicate and stay involved in discharge planning • Managing Your Congestive Heart Failure

o Important heart failure facts

• Resource: This link directs you to the AQIN Care Coordination Initiative patient tools:

http://atlanticquality.org/initiatives/care-coordination/care-coordination-ny/

IHI STate Action on Avoidable Rehospitalizations (STAAR) Initiative

The IHI STate Action on Avoidable Rehospitalizations (STAAR) Initiative was a four-year multi-

state approach to improve transitions of care and reduce avoidable rehospitalizations through

four key improvement areas:

• Perform an enhanced assessment of post-hospital needs • Provide effective teaching and facilitate enhanced learning

• Provide real-time hand over communications

• Ensure timely post-hospital care follow-up

Helpful tools on the IHI site include:

• STAAR overview documents • How-to guides customized for hospital to community settings, hospital to SNF, hospital

to home health care, and hospital to clinical office practice

• Diagnostic worksheets

• State policy maker checklist

• Issue briefs, webinars, presentations, and videos

• Resource: This link directs you to the IHI STAAR Initiative tools:

http://www.ihi.org/Engage/Initiatives/Completed/STAAR/Pages/Materials.aspx

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Re-Engineered Discharge (RED) Toolkit

The Re-Engineered Discharge (RED) Toolkit was developed the Boston University Medical

Center (BUMC) in conjunction with the Agency for Healthcare Research and Quality (AHRQ).

RED is effective at reducing readmissions and posthospital emergency department visits.

Contents of this exhaustive toolkit include how-to guides for:

• 11 steps for hospitals to implement RED

• The After Hospital Care Plan

• Delivering RED for diverse populations

• Post-discharge follow-up

• Monitoring implementation and outcome measures

• Enhance the role of family caregivers

• Resource: This link directs you to the AHRQ RED tools:

https://www.ahrq.gov/professionals/systems/hospital/red/toolkit/index.html

Part 2.6.2: Medication Reconciliation Tools Institute for Healthcare Improvement (IHI) Medication Reconciliation Content

The Institute for Healthcare Improvement (IHI) offers guidance on providing medication

reconciliation at all transition points to prevent medication errors that may lead to adverse

events and harm. IHI defines medication reconciliation as: “the process of creating the

most accurate list possible of all medications a patient is taking… and comparing that list

against the admission, transfer, and/or discharge orders.” The goal of medication reconciliation

is to ensure that the patient is receiving all the correct medications and to prevent unintended

changes or omissions of medications.

Recommended changes for improvement of medication reconciliation processes at all

transition points include:

• Reconcile admission orders with home medication lists on admission to the hospital

• Reconcile medication orders with the medications they were taking prior to admission when patients are transferred from one care unit to another

• Reconcile discharge instructions and prescriptions with the medication list collected at admission and the medication administration record

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In addition to these recommendations, other featured content on this page include:

• How-to Guide: Prevent Adverse Drug Events (Medication Reconciliation) — Rural Hospitals Supplement

o Developed as part of IHI's 5 Million Lives Campaign o Recommendations, implementation and follow-up measures specifically tailored

for rural hospitals

• Medication Reconciliation Review

o From the Mayo Health System in Eau Claire, Wisconsin, USA o How-to-guide providing step-by-step instructions for how to conduct a review to

identify discrepancies

• Medication Reconciliation Flowsheet

o From the Mayo Health System in Eau Claire, Wisconsin, USA o Tool designed for nurses to complete while reviewing medication orders

on admission and help determine next steps when an unreconciled medication is identified

• Medication Reconciliation Review: Data Collection Form

o From the Mayo Health System in Eau Claire, Wisconsin, USA o Another tool used to aggregate and monitor medication reconciliation over time

as an ongoing quality improvement effort

• Medication Reconciliation Form o From the Baptist Memorial Hospital, Memphis, a participant in the IHI’s Reducing

High Hazard Adverse Drug Events Breakthrough Series Collaborative

o Tool designed to track a patient’s medications upon admission, transfer, and discharge to decrease the rate of unreconciled medications

• Medication Safety Reconciliation Toolkit

o From the North Carolina Center for Hospital Quality and Patient Safety

• Resource: This link directs you to IHI “Reconcile Medications at All Transition Points” :

http://www.ihi.org/resources/Pages/Changes/ReconcileMedicationsatAllTransitionPoints.

aspx Free login is required to download tools on IHI site.

IHI also recommends changes for improvement of medication reconciliation processes in

outpatient settings:

• Collect and reconcile a medication list at each visit in outpatient settings and hospital- based clinics

• Include all medications (prescriptions, over-the-counter, herbals, supplements, etc.) with dose, frequency, route, and reason for taking

• Verify whether the patient is actually taking all medications as prescribed

• Ifanymedicationchangesaremadeasaresultofthevisit,givethepatientclear instruction on what to do and what follow-up is required

• Keep an ongoing medication list on file for recurring outpatients

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In addition to these recommendations, other featured content on this page include:

• Medication List for Patients and Families o From the Massachusetts Coalition for the Prevention of Medical Errors (in

collaboration with the Massachusetts Medical Society)

• My Medication Log

o From the New York City Department of Health and Mental Hygiene (DOHMH), Bureau of Chronic Disease Prevention and Control

• Resource: This link directs you to the IHI “Reconcile Medications in Outpatient Settings”

page: http://www.ihi.org/resources/Pages/Changes/ReconcileMedicationsinOutpatientSettings.

aspx

Free login is required to download tools on IHI site.

HealthIT.gov Medication Reconciliation EHR Meaningful Use Measure

HealthIT.gov sets meaningful use measures to help providers implement electronic health

records (EHRs). To help healthcare professionals meet the Medication Reconciliation

meaningful use measure, a collection of resources and tools are available to help perform

medication reconciliation at care transitions.

Select references from CMS and the National Learning Consortium include:

• CMS EHR Meaningful Use Specification Sheet for Eligible Professionals Medication Reconciliation

• Meaningful Use Case Studies

o From the Health Information Technology Resource Center (HITRC) o Case Studies that describe provider experiences and lessons learned throughout

EHR implementation and meaningful use

• Medication Reconciliation Tool

o From the Health Information Technology Resource Center (HITRC) o Guide including self-assessment and process model for how to meet the Medical

Reconciliation meaningful use

• Medication Discrepancy Tool (MDT) o From The Care Transitions Program, University of Colorado Denver, School of

Medicine

o Tool that helps identify and characterize medication discrepancies that arise when patients are transitioning between care settings

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• How to Create an Accurate Medication List in the Outpatient Setting through a Patient- Centered Approach

o From Consumers Advancing Patient Safety (CAPS), Aurora Health Care o Guidance for implementing a patient-centered approach to medication safety in

the outpatientsetting

• Resource: This link directs you to the HealthIT.gov medication reconciliation meaningful

use resources:

https://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-

measures/medication-reconciliation

North Carolina Center for Hospital Quality and Patient Safety Medication Safety

Reconciliation Tool Kit

The North Carolina Center for Hospital Quality and Patient Safety Medication Safety

Reconciliation Tool Kit is an extremely useful and detailed tool included as a resource on both

the IHI and HealthIT.gov references above.

This Tool Kit includes introductory materials detailing the scope of the problem of poor

medication reconciliation processes, particularly during transitions of care. The Tool Kit then

outlines process steps to establish and implement a medication reconciliation process and

includes sample process maps, algorithms, and forms which can be used to develop

performance improvement model. Several references, websites and example processes are

cited at the end for further information.

• Resource: This link directs you to the Medication Safety Reconciliation Tool Kit:

http://www.ncqualitycenter.org/wp-content/uploads/2013/01/MRToolkit.pdf

Part 2.6.3: Medication Management Tools American Medical Association (AMA) STEPS Forward Medication Adherence Module

The American Medical Association (AMA) STEPS Forward released a Medication Adherence

Module. This online module can be completed for 0.5 CME and downloadable tools are also

available. The module definesmedication nonadherence,howcommon it is,and whyit is

important to address before outlining the following eight steps to improve medication

adherence:

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• Consider medication nonadherence as the first reason a patient's condition is not under control

• Develop a process for routinely asking about medication adherence

• Create a blame‑free environment to discuss medications with the patient

• Identify why the patient is not taking their medicine

• Respond positively and thank the patient for sharing their behavior

• Tailor the adherence solution to the individual patient

• Involve the patient in developing thei rtreatment plan

• Set patients up for success

The reader will find tips to involve staff and patients in identifying nonadherence and changing

behaviors.

• Resource: This link directs you to the AMA Medication Adherence Module:

https://www.stepsforward.org/modules/medication-adherence

Healthcare Compliance Packaging Council (HCPC) White Paper

The Healthcare Compliance Packaging Council (HCPC) promotes the benefits of unit

dose packaging with compliance-prompting features to help people take their medications

properly. The HCPC released a White Paper on Improving Medication Adherence Through

Packaging. This White Paper defined “medication adherence” as the extent to which patients

follow provider recommendations about day-to-day medications with respect to the

timing, dosage, and frequency. The results of nine studies are shared that support their

position. Compliance packaging (i.e. calendar-oriented, unit-dose, structured, blister

packaging, reminder cards) results in decreased confusion and misunderstanding and

increased adherence and compliance.

• Resource: This is the citation for the HCPC White Paper:

Improving Medication Adherence Through Packaging. Healthcare Compliance Packaging

Council. Available at: http://www.hcpconline.org/. Accessed August 18, 2017.

Guide for Identifying and Resolving Discharge Medication Accessibility Problems in New York

State

The Atlantic Quality Improvement Network (AQIN) Quality Improvement Organization (QIN) for

New York State, South Carolina, and the District of Columbia prepared a “Guide for Identifying

and Resolving Discharge Medication Accessibility Problems in New York State” which outlines

potential problems and guidance for resolution to help identify potential drug therapy and

community pharmacy problems

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• Resource: This link directs you to the AQIN medication accessibility problems guide:

https://atlanticquality.org/download/508_NYS-Guide_Ident_Resolv_Access_Prob.pdf

Optimizing Discharge Medication Lists

In a study by Backes et al published in The Consultant Pharmacist, a needs assessment

performed care transitions pharmacist identified opportunities to optimize discharge

medication lists in skilled nursing facilities. The goal of this pilot study was to increase patient

safety, reduce medication errors and prevent medication-related hospital readmissions through

optimization of discharge medication lists.

Some ideal components of a skilled nursing facility discharge medication list listed in Table 1

include:

• Generate an electronic list to minimize human error risk

• List both brand and generic medication names

• Avoid using sig codes and medical abbreviations

• Provide indications for all medications in layperson terms

• Determine if hold parameters are appropriate and understood by patient and/or caregiver

• Eliminate unnecessary protocol medications • Consider font size and layout to maximize readability

• Resource: This is the citation for the discharge medication lists pilot study:

Backes AC, Cash P, Jordan J. Optimizing the use of discharge medication lists in nursing

facilities. Consult Pharm 2016;31:493-9.

Part 2.6.4: Deprescribing Tools Deprescribing Tools

Canadian Deprescribing Network (CaDeN) Deprescribing Tools

The Canadian Deprescribing Network (CaDeN) created several deprescribing guidelines for

reducing or stopping potentially unnecessary or harmful medications. These guidelines target the

following classes of medications: antipsychotics, benzodiazepines and Z-drugs, proton pump

inhibitors, antihyperglycemics, and antihistamines. Resources available for download include:

guidelines, algorithms, information pamphlets, and links to several helpful

polypharmacy and deprescribing resources. Patient decision aids are coming soon.

• Resource: This link directs you to the CaDeN deprescribing tool:

http://deprescribing.org/resources/

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Canadian Deprescribing Network Video: The steps involved in deprescribing – shared decision-making with patients This 55-minute video presented by Barbara Farrell, PharmD from the Canadian Deprescribing.org initiative focuses on the shared decision-making and patient engagement aspect of deprescribing conversations. It provides an evidence-based review of the shared decision-making process, impact on care, and barriers and enablers in conversations. Additionally, it describes in detail the steps in the shared decision-making process in the context of deprescribing and sample statements for each step.

Resource: Deprescribing.org. The steps involved in deprescribing - shared decision-making with patients. June 27, 2018. Retrieved from: https://www.youtube.com/watch?v=Ywzhd0cj7Ls&t=53s

Veterans Affairs Health System’s VIONE Deprescribing Tool

The Veterans Affairs (VA) Healthcare System developed a tool to provide guidance to clinicians and patients on deprescribing medications that are potentially or actually unsafe, not needed, or whose risks outweigh the benefits to promote patient safety and quality of life. It divides medications into five categories and provides decision-making action plans. The tool was shown to decrease pill burden, cost, side effects, medication errors, and ER and hospital visits while increasing freedom and quality of life.

Clinicians Patients

Vital Is the medication a life-saving medication?

Continue and adjust as needed

Is this medication vital and essential for my health?

Important Is the medication important for quality of life?

Continue and consolidate where possible

How important is this medication to improve my quality of life and my health?

Optional Does this medication make no major difference if it is continued?

Weigh risk vs benefits

Do I absolutely need to take this medicine or is it option?

Is it safe to stop this medicine or take it in smaller doses?

Not indicated Is this medication or treatment no longer indicated?

Stop or taper off medication

Am I taking any medications that are no longer appropriate or needed?

Can these be stopped or decreased?

Every medication has a reason

Every medication has to have a diagnosis and indication for use that is reassessed and justified.

Does every medication that I take have a clear reason or diagnosis? If not, is it important to ask my provider why I am taking it?

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● Resource: With permission from the VA, you can find VIONE-related documents at these links:

○ VIONE Brochure for Clinicians and Pharmacists

■ https://cdn.ymaws.com/www.ascp.com/resource/collection/F8747848-F634-4F82-B1E0-F1DE4340BFD6/VIONE_Brochure_for_Clinicians_and_Pharmacists_10_10_2018.pdf

○ VIONE Brochure for Patients

https://cdn.ymaws.com/www.ascp.com/resource/collection/F8747848-F634-4F82-B1E0-F1DE4340BFD6/VIONE_Brochure_08_08_2018.pdf

○ VIONE Vignette

■ https://cdn.ymaws.com/www.ascp.com/resource/collection/F8747848-F634-4F82-B1E0-F1DE4340BFD6/VIONE_Vignette_Nov_2018.pdf

The VIONE workgroup can be reached at VAVIONE@va.gov with questions.

Primary Health Tasmania Deprescribing Guides

Primary Health Tasmania (Tasmania PHN) is a non-government, non-for-profit organization under the Australian Government’s Primary Health Networks Program. They provide targeted support for general practice through resources, professional development, training and networking. They have guides outlining deprescribing strategies for medicines including allopurinol, antihyperglycemics, antihypertensives, antipsychotics, aspirin, benzodiazepines, bisphosphonates, cholinesterase inhibitors, glaucoma eye drops, NSAIDs, opioids, proton pump inhibitors, statins and vitamin D and calcium. They also have a consumer-focused brochure to facilitate a conversation with providers about deprescribing, and a series of short videos about the deprescribing cycle.

● Resource:

https://www.primaryhealthtas.com.au/resources/deprescribing-resources/

MedStopper

MedStopper is an interactive website where the user can input lists of medications and the

conditions for which medications are used to generate a list of potentially inappropriate

medications that may be deprescribed. The MedStopper Plan displays the medications in

order of stopping priority with RED signifying the highest priority, and GREEN the lowest

priority. This Plan can be printed.

Recommendations for drugs to stop take into consideration:

• Frail elderly scale

• Potential for improving symptoms or reducing risk for future illness or causing harm

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• Whether on Beers or STOPP criteria • Whether tapering is suggested

• Resource: This link directs you to the interactive MedStopper website:

http://medstopper.com/

Prioritization and Stopping Medications

In “Prioritization and Stopping Medications”, Alexander et al. outline opportunities for

prioritization or discontinuation of medications based on degree of uncertainty and

reason for action. Medications may be discontinued with none or minimal uncertainty to

correct a medical error, to simplify regimen, when clinical benefit is unlikely, or when safe for

use on an as- needed basis. With moderate stakes, a drug discontinuation trial is appropriate

because benefit has likely been achieved, a behavioral intervention can be substituted, or

benefit is unlikely to be realized. With high stakes, careful prioritization is necessary.

Real-world examples of patients are provided for each risk scenario above.

• Resource: This is the citation for the prioritization and stopping medications article:

Alexander C, et al. Prioritizing and stopping prescription medicines. Canadian Medical

Association Journal. 2006; 174(6): 1083-4.

Medication Appropriateness for Patients Late in Life

In “Reconsidering Medication Appropriateness for Patients Late in Life”, Holmes et al. proposed

a model for appropriate prescribing for patients late in life that considers:

• Remaining life expectancy

• Time until benefit will be achieved

• Goals of care

• Treatment targets

The goal of this model is to serve as a guide for discontinuation or withholding of

treatments otherwise indicated, appropriate and recommended according to current

guidelines.

• Resource: This is the citation for the medication appropriateness late in life article:

Holmes H, et al. Reconsidering medication appropriateness for patients late in life.

Archives of internal medicine. 2006; 166(6): 605-9.

Good Palliative-Geriatric Practice Algorithm

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The Good Palliative-Geriatric Practice algorithm was designed for nursing homes to

reduce polypharmacy. A series of questions determine whether drugs should be continued at the

same dose, reduce the dose, stop the drug, or switch to another drug. The algorithm assesses

if:

• Indication is valid and relevant

• Possible adverse reactions outweigh possible benefits

• Drug causing adverse signs or symptoms

• Another drug is superior

• Dose can be reduced without significant risk

When tested in nursing homes in Israel, the algorithm reduced mortality, hospitalization, and

cost with low rate of drug discontinuation failure.

• Resource: This is the citation for the Good Palliative-Geriatric Practice algorithm:

Garfinkel D, Zur-Gil S, Ben- Israel J. The war against polypharmacy: a new cost-effective

geriatric-palliative approach for improving drug therapy in disabled elderly people. Isr

Med Assoc J2007;9(6):430–4.

Deprescribing Studies

De-PRESCRIBE trial

In “Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults, The De-PRESCRIBE Randomized Clinical Trial”, Martin et al. outlined consumer-targeted, pharmacist-led interventions that resulted in greater discontinuation of inappropriate prescriptions (sedative-hypnotics, glyburide, and NSAIDs) compared with usual care after 6 months. Educational materials for patients consisted of a drug-specific brochures (i.e. sedative-hypnotics, sulfonylureas, NSAIDs). Educational materials for physicians consisted of pharmacist-physician communication sheets for each of the agents.

● Resource: Martin, P, Tamblyn R, Benedetti A, et al. “Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults, The De-PRESCRIBE Randomized Clinical Trial. JAMA. 2018;320(18):1889-1898.

EMPOWER trial

The EMPOWER (Eliminating Medications Through Patient Ownership of End Results) trial, reported by Tannenbaum et al, was conducted in community pharmacies using direct-to-consumer educational interventions against usual care to assess benzodiazepine therapy discontinuation among community-dwelling older adults over a 6-month follow-up period. The primary outcome is the complete cessation of benzodiazepines, or dose reduction (at least 25% reduction of baseline dose). The study group participants received a Canadian

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Deprescribing Network brochure, which describes the risks of benzodiazepine and hypnotic use, education about drug interactions, suggestions of therapeutic substitution for insomnia and anxiety, and step-wise tapering recommendations. Results showed 27% of study group participants achieved complete benzodiazepine cessation and 11% achieved dose reduction, compared to 5% and 6% respectively in the control group. Discouragement from their physicians/pharmacists or fear of withdrawal symptoms were the most common reason reported by those elected not to taper/stop. These results show the effectiveness in deprescribing utilizing direct-to-consumer interventions at the community pharmacy setting, highlighting the role of community pharmacists in the deprescribing of potentially problematic medications.

● Resource: Tannenbaum C, Martin P, Tamlyn R, Benedetti A, et al. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education. The EMPOWER Cluster Randomized Trial. JAMA Intern Med 2014;174:890-98. Doi:10.1001/jamainternmed.2014.949

Access full article through https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1860498

Institute for Healthcare Improvement: Publications on Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines

Innovation Case Study

McCarthy presents a case study about a multidisciplinary team of clinical experts who focused on developing and implementing deprescribing guidelines for tapering and stopping medications for elderly adults. The project and research team consisted of three researchers and four health care leaders who collaborated to create guidelines on how to implement a deprescribing process to discontinue unnecessary or inappropriate medications. They found that long-term care facilities adopted the implementation process more than community-centered family health teams and those that implemented the deprescribing guidelines found the process useful and that it also created an interdisciplinary approach to patients’ healthcare.

Implementation Guide

A multidisciplinary team of clinical experts from Ottawa, Canada adapted a deprescribing innovation adopted by a US healthcare system into a Deprescribing Implementation Guide. The guide consists of 4 phases: 1) Set-Up, 2) Develop the Scalable Unit, 3) Test Scale-Up, and 4) Go to Full Scale. The basis of the 4 phases is to establish a specific goal for deprescribing such as what medication will be deprescribed, how much reduction is needed, by what time frame, and in which population of patients. Based on that goal, a protocol must be developed to test on a small scale unit before using on a full scale unit in the healthcare system.

● Resource:

1. McCarthy D. Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017.

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2. Pelton L, Knihtila M. Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines — Implementation Guide. Boston, Massachusetts: Institute for Healthcare Improvement; 2018.

Access with login through free account: http://www.ihi.org/resources/pages/publications/evidence-based-medication-deprescribing-innovation-case-study.aspx

Tools for Deprescribing in Frail Older Persons and those with Limited Life Expectancy

Thompson et al performed a systematic review of the literature to outline different deprescribing tools that can be used in frail older persons and those with limited life expectancy. They divided the tools into the categories of models/frameworks for approaching deprescribing, outlined a deprescribing approach when reviewing the entire medication list, and provided medication-specific advice. Additionally, throughout the article, the authors reference the tool, category of the tool, population of interest for the tool, and a brief description of it in an easy to read table format.

● Resource: This is the citation for the article:

Thompson W, Lundby C, Graabaek T, et al. Tools for Deprescribing in Frail Older Persons and those with Limited Life Expectancy: A Systematic Review. J Am Geriatr Soc 2019;67(1):172-180. doi: 10.1111/jgs.15616

Free PDF Access (https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.15616)

Health Care Professionals’ Attitudes Toward Deprescribing in Older Patients with Limited Life Expectancy: A Systematic Review

Lundby et al reviewed literature from inception through 2017 regarding deprescribing views in older patients with limited life expectancy. The authors identified eight studies exploring these views, mostly from the perspective of general practitioners. Four themes were identified regarding attitudes around deprescribing: (1) Patient and relative involvement, (2) The importance of teamwork, (3) Health care professionals’ self-assurance and skills, and (4) The impact of organizational factors. Some sub-themes included difficulties around cognitive impairment, pressures from family, reluctance to engage in collaborative care, lack of confidence and level of responsibility of practitioner, and staffing and workflow issues. Considering that few studies were identified and themes include multiple factors that are highly interdependent, it is the opinion of the authors that there is urgent need for more research in the area.

● Resource: This is the citation for the deprescribing and limited life expectancy article:

Lundby C, Graabaek T, Ryg J, et al. Health care professionals’ attitudes towards deprescribing in older patients with limited life expectancy: A systematic review. Br J Clin Pharmacol 2019 Jan 10 [Epub ahead of print]. DOI:10.1111/bcp.13861

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Free access on website

PDF Version: https://bpspubs.onlinelibrary.wiley.com/doi/epdf/10.1111/bcp.13861

Feasibility Study of a Systematic Approach

Garfinkel et al performed a feasibility study on the Good Palliative-Geriatric Practice (GP-GP) algorithm in community-dwelling older patients. The goal of the study was to explore whether this algorithm could be implemented to reduce polypharmacy in older patients. Through patient assessment and incorporation of the GP-GP algorithm, clinicians had discussions with the patient/guardian to determine if deprescribing was appropriate. If discontinuing medications was inappropriate, other options included a dose reduction or shift to another drug. Favorable outcomes included discontinuation of 311 medications in 64 patients. The authors comment that this study may be limited due to the small sample, which may not be representative of the heterogeneous population, and there was no data to assess if patients were treated inappropriately before the study was done.

● Resource: Garfinkel D, Mangin D. Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults: Addressing Polypharmacy. Arch Intern Med. 2010;170(18):1648–1654. doi:10.1001/archinternmed.2010.355

Free access of the article is available: JAMA (Algorithm and Charts are available in side tabs)

PDF Version: (http://www.crebp.net.au/wp-content/uploads/2014/06/Feasibility-study-of-a-systematic-approach.pdf)

Deprescribing Informational Literature

Palliative Care Network of Wisconsin (PCNOW) Fast Facts and Concepts

Fast Facts are developed to provide concise, practical, peer-reviewed and evidence-based summaries on key palliative care topics. These are useful for clinicians and trainees caring for patients facing serious illness. Fast Fact #321 provides a general overview of deprescribing. Topics included in this Fast Fact are potentially inappropriate medications at the end of life, barriers to deprescribing, deprescribing framework and the process of deprescribing. Four other Fast Facts (#236, 258, 278, and 322) provide recommendations for managing specific topics at end of life, including if/how to treat a venous thromboembolism in advanced cancer, diabetes management, warfarin and palliative care, and statins.

● Resources:

1. Fast Facts #236 (Pharmacologic Treatment of Acute VTE Advanced Cancer)

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https://www.mypcnow.org/blank-ozshq

2. Fast Facts #258 (Diabetes Management at the End of Life)https://www.mypcnow.org/blank-agxj1

3. Fast Facts #278 (Warfarin and Palliative Care)https://www.mypcnow.org/blank-defio

4. Fast Facts #321 (Deprescribing)https://www.mypcnow.org/copy-of-fast-fact-320

5. Fast Facts #322 (Discontinuation of Statins at End of Life)https://www.mypcnow.org/copy-of-fast-fact-321

Ashton Manual for Deprescribing Benzodiazepines In this manual, Professor Ashton provides information on why patients should come off of benzodiazepines after long-term use as well as steps to take before starting the withdrawal process. Chapter I describes the benefits of deprescribing benzodiazepines to avoid the unwanted side effects such as poor memory and cognition, emotional blunting, depression and increasing anxiety. Chapter II provides guidance for slowly tapering or switching from short- to long-acting benzodiazepines and designing an individualized schedule with instructions on tapering doses in weekly intervals. Chapter III describes acute and protracted benzodiazepine withdrawal symptoms.

Resource: C Heather Ashton. Benzodiazepines: How They Work and How To Withdraw. Revised August 2002; © Copyright 1999-2013. Available at https://www.benzo.org.uk/manual/index.htm

Part 2.6.5: Risk Screening Tools

The LACE Index

The LACE Index is a scoring tool that identifies patients at high risk for readmission or

death within 30 days of discharge from hospital. LACE scores range from 1-19. A score of 0 – 4

= Low; 5 – 9 = Moderate; and a score of ≥ 10 = High risk of readmission.

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LACE stands for:

• “L” = length of stay

• “A” = acuity of admission (i.e. through the Emergency Department vs. elective admission)

• “C” = co-morbidities

• “E” = Emergency Department visits within the last 6 months

This Index can help pharmacists target and prioritize patients who would benefit most from

medication reconciliation and education on transition

• Resource: This link directs you to the LACE index:

http://www.besler.com/lace-risk-score/