Medication optimization in nursing homes: the impact of education and interdisciplinary case conferencing

Abstract

Introduction: Potentially inappropriate prescribing has shown to be highly prevalent in older adults, especially in nursing home residents. Previous research, such as the Come-On study, proved that a complex intervention, containing an educational component and interdisciplinary case conferencing, is effective in reducing this phenomenon. 
 Policy context and objective: Awaiting the structural implementation supported by the government, an initiative was set up in West-Flanders to locally implement such an intervention and explore its impact.
 Target population: This study targeted nursing home residents and nursing home staff.
 Innovation, impact, outcomes: The intervention included three components: 1) education of nursing home staff by the pharmacist with regard to medication use in nursing home residents, 2) interdisciplinary case conferencing during which medication plans of residents were discussed (i.e. medication review) by the resident’s general practitioner (or the nursing home’s coordinating physician), a nurse, and the pharmacist, and 3) intervision across nursing homes to discuss experiences. Nursing homes were encouraged to involve residents and family members as much as possible (e.g. to invite them to the interdisciplinary case conference). For each case conference, nursing homes were instructed to report the duration, the identified (potential) drug-related problems, and the proposed medication changes. Throughout the study, financial incentives were provided for pharmacists and nursing homes.
 Quantitative data were analyzed descriptively, while qualitative data were analyzed inductively. Furthermore, an economic evaluation was performed.
 Eight nursing homes participated in the study. Nursing home staff indicated to have better medication-related knowledge and to be more aware of potential drug-related problems thanks to their participation in the project. They also experienced better communication between all involved healthcare professionals and with residents and their families.
 So far, data with regard to the interdisciplinary case conferences has been collected from five nursing homes, encompassing 266 nursing home residents. An interdisciplinary case conference lasted on average about 30 minutes per resident. For 60% of these nursing home residents, at least one medication change was implemented (e.g. stopping of a drug, change of administration time or route, change of dosage form). The five most frequently stopped drugs included 1) vitamins and supplements, 2) psychotropic drugs, 3) pain killers, 4) PPIs, and 5) antihypertensive drugs. On average, this resulted in a saving of €105 per year per resident.
 It was noted that general practitioners only participated in the case conferences in one nursing home. Likewise, residents nor family members were present during the interdisciplinary meetings. Nevertheless, residents (and families) were interviewed regarding their medication use in preparation of the conference and were informed about medication changes afterwards. 
 Transferability and conclusion: The intervention was shown to be effective in optimizing the medication use of nursing home residents. Following steps will focus on the implementation of the intervention in a higher number of nursing homes, as well as in other home replacing settings. Additionally, opportunities for involvement of residents and their families, as well the participation of general practitioners will be further investigated.
 Key words: Residential care, interdisciplinary case conferences, inappropriate prescribing, medication review