Nursing Home Teams Research Articles

Evaluating Real-World Implementation of INFORM (Improving Nursing Home Care through Feedback on Performance Data): An Improvement Initiative in Canadian Nursing Homes

INFORM (Improving Nursing Home Care through Feedback on Performance Data) was a research intervention that equipped nursing home managers with skills to conduct local improvement projects and supported them in improving performance through modifiable elements in their units. Prior reports have found positive and sustained outcomes from INFORM intervention. In this article, the authors report findings from a formative service evaluation of INFORM as modified for implementation in real-world settings. INFORM was transformed for real-world implementation with an initial cohort of 26 nursing homes in British Columbia, Canada (INFORM BC). Three stakeholder groups were involved: nursing home teams, an academic team that modified INFORM for implementation, and a BC team that implemented INFORM and coached participating nursing home teams in applying it locally. Service evaluation was conducted drawing on participants from all three stakeholder groups, using convenience sampling, with numbers varying by data source. Using a mixed methods design, outcome data included qualitative and quantitative assessment of surveys, discussions, observations, and a review of documents and resources. The majority of nursing home teams reported positive outcomes relative to the usefulness and relevance of the initiative for local needs despite a number of operational challenges during implementation. A key factor in their success was combining targeted external support with the opportunity to set goals and measure success locally. Challenges included a lack of time at the nursing home level, COVID-19-related disruptions, and issues with role clarity and alignment of expectations among the academic and BC teams. INFORM BC advanced the processes of change planning and transferable learning among nursing home managers and their local teams. Success was facilitated externally but defined and achieved locally. Future iterations should probe outcome sustainability and how nursing home teams adapt the INFORM approach in practice.

ADVANCED-COMFORT: TESTING A CARE PLANNING INTERVENTION FOR NURSING HOME RESIDENTS WITH ADVANCED DEMENTIA

Abstract Many nursing home (NH) residents with advanced dementia receive burdensome interventions rather than interventions that promote comfort or quality of life. The purpose of this study was to test the usability of a novel intervention called ADVANCED-Comfort that aims to enhance the provision of personalized, comfort focused care for residents with advanced dementia. The intervention consisted of structured care plan meetings between the NH team and proxies of residents with dementia (e.g., family members). Using the ADVANCED-Comfort workbook, proxies and staff created individualized care plans addressing 6 domains adapted from the Age Friendly Health System Framework (what Matters; Meaningful activities; Mealtime; Mobility; Medications and treatments; and Make comfortable). We evaluated the intervention using surveys, observation, and exit interviews. We found the intervention to be highly usable (acceptable, appropriate, and feasible) and exit interviews identified several promising outcomes. Both families and staff reported that the intervention improved communication and trust. Families reported that they had a newfound trust in staff to provide consistent quality care. Staff reported that the intervention helped them build better relationships with families and allowed families to articulate what they prefer rather than waiting until “something goes wrong.” Staff also reported that the intervention improved their excitement to go to work and enhanced their sense of teamwork. Finally, both staff and proxies reported exciting implications for residents such as a reduction in antipsychotic medication, decrease in distressed behaviors, weight stabilization, and initiation of hospice. Based on these preliminary findings, additional testing of the ADVANCED-Comfort intervention is warranted.

Advanced-Comfort: Usability Testing of a Care Planning Intervention for Nursing Home Residents With Advanced Dementia.

Many nursing home (NH) residents with advanced dementia receive burdensome interventions rather than interventions that promote comfort or quality of life. The purpose of the current study was to test the usability of a novel intervention, ADVANCED-Comfort, which aims to enhance the provision of personalized care for residents with advanced dementia. The intervention comprises structured care plan meetings between the NH team and proxies of residents with dementia (e.g., family members). Using the ADVANCED-Comfort workbook, proxies create individualized care plans addressing six domains adapted from the Age-Friendly Health System Framework. The purpose of this article is to describe the intervention and its theoretical underpinnings and report the usability of the intervention evaluated with surveys, observation, and exit interviews. The study demonstrated that proxies and NH staff found the intervention usable (acceptable, appropriate, and feasible). Based on these preliminary findings, additional testing of the ADVANCED-Comfort intervention is warranted. [Journal of Gerontological Nursing, 49(11), 15-23.].

Development and validation of the Overall Fidelity Enactment Scale for Complex Interventions (OFES-CI)

BackgroundIn many quality improvement (QI) and other complex interventions, assessing the fidelity with which participants ‘enact’ intervention activities (ie, implement them as intended) is underexplored. Adapting the evaluative approach used...

204 DEDICATED NURSING HOME SERVICE IN A TERTIARY HOSPITAL: EFFECT ON ADMISSION NUMBERS AND LENGTH OF STAY

Abstract Background In 2019 a dedicated Nursing Home (NH) in-patient service was established in a tertiary hospital, comprising a Consultant Geriatrician, clinical nurse specialist, NCHD and administrative support. All NH residents over 65 with medical diagnoses were admitted by the NH team who also provide a consult service for NH residents under other specialties. Methods Data were sourced from the Hospital Inpatient Enquiry system on length of stay of patients identified as admitted from a nursing home compared to those admitted under the NH team and their average lengths of stay over 2019-2021. Results In 2019, 749 NH residents were admitted to hospital with an average length of stay (ALOS) of 7.93 days, the NH inpatient service was established in July 2019 and showed a reduction of ALOS from 9.25 to 6.6 days in the 6 months following its establishment (29% difference.) In 2020, 707 NH residents were admitted with 352 admitted under the NH team. The ALOS of NH residents admitted under the NH team was 5.66 days in 2020 compared to 8.65 overall (35% difference.) In 2021, 765 NH residents were admitted with 402 under the NH team. ALOS of NH residents admitted under the NH team was 5.33 days in 2021 compared to 8.28 overall (36% difference.) Conclusion Within six months of its commencement the dedicated NH service had decreased length of stay by 29%. The average length of stay across all services has decreased year on year from 6.6 to 5.3 days from 2019 to 2021. The ALOS in the total cohort (including residents admitted surgically and those under 65) was 29-36% higher. Though difficult to accurately compare these cohorts due to different presenting diagnoses and medical backgrounds in those admitted surgically or those under 65, the overall reduction in length of stay over the three years does highlight the benefit from this dedicated service.

Communication Disparities between Nursing Home Team Members.

Optimal care in nursing home (NH) settings requires effective team communication. Certified nursing assistants (CNAs) interact with nursing home residents frequently, but the extent to which CNAs feel their input is valued by other team members is not known. We conducted a cross-sectional study in which we administered a communication survey within 20 Utah nursing home facilities to 650 team members, including 124 nurses and 264 CNAs. Respondents used a 4-point scale to indicate the extent to which their input is valued by other team members when reporting their concerns about nursing home residents. We used a one-way ANOVA with a Bonferroni correction. When compared to nurses, CNAs felt less valued (CNA mean = 2.14, nurse mean = 3.24; p < 0.001) when reporting to physicians, and less valued (CNA mean = 1.66, nurse mean = 2.71; p < 0.001) when reporting to pharmacists. CNAs did not feel less valued than nurses (CNA mean = 3.43, nurse mean = 3.37; p = 0.25) when reporting to other nurses. Our findings demonstrate that CNAs feel their input is not valued outside of nursing, which could impact resident care. Additional research is needed to understand the reasons for this perception and to design educational interventions to improve the culture of communication in nursing home settings.

Nursing Administrative Support Role Proves Reduction in Nursing Overtime and Staff Turnover

Nursing Administrative Support Role Proves Reduction in Nursing Overtime and Staff Turnover

Integrating Principles of Safety Culture and Just Culture Into Nursing Homes: Lessons From the Pandemic.

Decades of concerns about the quality of care provided by nursing homes have led state and federal agencies to create layers of regulations and penalties. As such, regulatory efforts to improve nursing home care have largely focused on the identification of deficiencies and assignment of sanctions. The current regulatory strategy often places nursing home teams and government agencies at odds, hindering their ability to build a culture of safety in nursing homes that is foundational to health care quality. Imbuing safety culture into nursing homes will require nursing homes and regulatory agencies to acknowledge the high-risk nature of post-acute and long-term care settings, embrace just culture, and engage nursing home staff and stakeholders in actions that are supported by evidence-based best practices. The response to the COVID-19 pandemic prompted some of these actions, leading to changes in nursing survey and certification processes as well as deployment of strike teams to support nursing homes in crisis. These actions, coupled with investments in public health that include funds earmarked for nursing homes, could become the initial phases of an intentional renovation of the existing regulatory oversight from one that is largely punitive to one that is rooted in safety culture and proactively designed to achieve meaningful and sustained improvements in the quality of care and life for nursing home residents.

Is it possible to influence ability, willingness and understanding among nursing home care staff to implement nutritional guidelines? A comparison of a facilitated and an educational strategy.

Translating nutrition knowledge into care practice is challenging since multiple factors can affect the implementation process. This study examined the impact of two implementation strategies, that is external facilitation (EF) and educational outreach visits (EOVs), on the organisational context and individual factors when implementing nutritional guidelines in a nursing home (NH) setting. The EF strategy was a one-year, multifaceted (including support, guidance, a practice audit and feedback) intervention given to four NH units. The EOV strategy was a three-hour lecture about the nutritional guidelines given to four other NH units. Both strategies were directed at selected NH teams, consisting of a unit manager, a nurse and 5-10 care staff. A questionnaire was distributed, before and after the interventions, to evaluate the prerequisites for the staff to use the guidelines. Three conditions were used to examine the organisational context and the individual factors: the staff's ability and willingness to implement the nutritional guidelines and their understanding of them. Confirmatory factor analysis and structural equation models were used for the data analysis. The results indicated that on average, there was a significant increase in the staff's ability to implement the nutritional guidelines in the EF group. The staff exposed to the EF strategy experienced better resources to implement the guidelines in terms of time, tools and support from leadership and a clearer assignment of responsibility regarding nutrition procedures. There was no change in staff's willingness and understanding of the guidelines in the EF group. On average, no significant changes were observed for the staff's ability, willingness or understanding in the EOV group. A long-term, active and flexible implementation strategy (i.e. EF) affected the care staff's ability to implement the nutritional guidelines in an NH setting. No such impact was observed for the more passive, educational approach (i.e. EOV).

DEMENTIA CARE AND BEHAVIORAL HEALTH WORKFORCE DEVELOPMENT: INNOVATIONS IN TRAINING ACROSS SETTINGS

It is well-established that there is a critical shortage of trained health care staff who can deliver high-quality behavioral health services to persons with dementia. The development of innovative professional training curricula, and effectively implementing and sustaining such programs, is a key element in addressing this workforce crisis. This symposium highlights cutting-edge efforts being conducted across the continuum of care, to train health care professionals to support optimal behavioral health for persons with dementia. In the outpatient setting, Wyman et al. present data from a survey of mental health clinicians on their perspectives about working with persons with dementia and caregivers, revealing critical gaps in knowledge and skills to target in continuing education programming. Wray and colleagues focus on integrated behavioral health in primary care, discussing how geriatric experts can most effectively contribute to improved assessment and treatment within this setting. Koepp presents an innovative program to transform outpatient mental health care for persons with dementia through provider training and consultation. In the residential care setting, Reinhardt and colleagues report on the implementation of a comprehensive approach to the alleviation of behavioral health problems through training direct care staff in person-directed care in nursing homes. Finally, Karel et al share how VA interprofessional nursing home teams learn and sustain an evidence-based program to address behavioral concerns among residents with dementia. The discussant will lend a deep expertise in research and policy related to the geriatric workforce to her remarks on the presentations.

Negative prompts aimed at maintaining eating independence.

Psychological abuse of older people is difficult to recognise; specifically, nursing home residents have been documented to be at higher risk of psychological abuse during daily care, such as during feeding. Healthcare professionals adopt positive and negative verbal prompts to maintain residents' eating independence; however, negative prompts' purposes and implications have never been discussed to date. To critically analyse negative verbal prompts given during mealtimes as forms of abuse of older individuals and violation of ethical principles. This is a secondary analysis of three cases of negative prompts that emerged in a large descriptive study based upon focus group methodology and involving 13 nursing homes and 54 healthcare professionals. This study included 3 out of 13 nursing homes caring for residents with moderate/severe functional dependence in self-feeding mainly due to dementia; in these nursing homes, we conducted three focus groups and 13 healthcare professionals participated. This study was conducted in accordance with the Human Subject Research Ethics Committee guidelines after being approved by the Review Board of the Trust. With the intent of maintaining self-feeding independence, negative verbal prompts have been reported as being used by nursing home teams. By critically analysing these negative prompts, it turned out they could trigger intimidation, depression and anxiety and thus could be considered as forms of abuse; moreover, negative prompts can threaten the ethical principles of (1) autonomy using a paternalist approach, (2) beneficence and non-maleficence as with the intent to act in the best interests of residents (to maintain self-feeding independence) they are harmed in their dignity and (3) justice, given that residents who received negative prompts are treated differently from those who received positive prompts. Eating should be a pleasant experience with a positive impact on physiological, psychological and social well-being. However, negative prompting can lead to abuse and violation of basic ethical principles, destroying the healthcare professional resident and relative relationships strongly dependent on trust. Negative verbal prompting must be avoided.

Long-term behavior change detection approach through objective technological observations toward better adaptation of services for elderly people

Behavior change is associated with important decrease of cognitive and physical capacities among elderly people. Therefore, a proactive detection of long-term behavior changes in early stages of their evolution is a keystone to improve elderly healthcare services. In fact, nowadays’ geriatric methods mainly rely on scales and questionnaires, and are inconvenient to investigate long-term changes on a daily basis. Therefore, our proposed approach for behavior change detection analyzes elderly people behavior over long periods via ambient technologies. In fact, employed technologies are unobtrusive, do not interfere with the natural behavior of elderly people and do not affect their privacy. Furthermore, our long-term behavior analysis is based on the identification of significant behavior change indicators (e.g., mobility, memory, nutrition and social life indicators significantly correlate with cognitive and physical diseases), and the application of efficient statistical techniques that differentiate long-term and short-term changes in analyzed behavior. In addition, our two-year deployment validates our objective technological observations through real correlations with medical observations of nursing-home team.

The OptimaMed intervention to reduce inappropriate medications in nursing home residents with severe dementia: results from a quasi-experimental feasibility pilot study

BackgroundMedication regimens in nursing home (NH) residents with severe dementia should be frequently reviewed to avoid inappropriate medication, overtreatment and adverse drug events, within a comfort care approach. This study aimed at testing the feasibility of an interdisciplinary knowledge exchange (KE) intervention using a medication review guidance tool categorizing medications as either “generally”, “sometimes” or “exceptionally” appropriate for NH residents with severe dementia.MethodsA quasi-experimental feasibility pilot study with 44 participating residents aged 65 years or over with severe dementia was carried out in three NH in Quebec City, Canada. The intervention comprised an information leaflet for residents’ families, a 90-min KE session for NH general practitioners (GP), pharmacists and nurses focusing on the medication review guidance tool, a medication review by the pharmacists for participating residents with ensuing team discussion on medication changes, and a post-intervention KE session to obtain feedback from team staff. Medication regimens and levels of pain and of agitation of the participants were evaluated at baseline and at 4 months post-intervention. A questionnaire for team staff explored perceived barriers and facilitators. Statistical differences in measures comparing pre and post-intervention were assessed using paired t-tests and Cochran’s-Q tests.ResultsThe KE sessions reached 34 NH team staff (5 GP, 4 pharmacists, 6 heads of care unit and 19 staff nurses). Forty-four residents participated in the study and were followed for a mean of 104 days. The total number of regular medications was 372 pre and 327 post-intervention. The mean number of regular medications per resident was 7.86 pre and 6.81 post-intervention. The odds ratios estimating the risks of using any regular medication or a “sometimes appropriate” medication post-intervention were 0.81 (95% CI: 0.71–0.92) and 0.83 (95% CI: 0.74–0.94), respectively.ConclusionA simple KE intervention using a medication review guidance tool categorizing medications as being either “generally”, “sometimes” or “exceptionally” appropriate in severe dementia was well received and accompanied by an overall reduction in medication use by NH residents with severe dementia. Levels of agitation were unaffected and there was no clinically significant changes in levels of pain. Staff feedback provided opportunities to improve the intervention.

Changing the Impact of Nursing Assistants' Education in Seniors' Care: the Living Classroom in Long-Term Care.

BackgroundEvidence-informed care to support seniors is based on strong knowledge and skills of nursing assistants (NAs). Currently, there are insufficient NAs in the workforce, and new graduates are not always attracted to nursing home (NH) sectors because of limited exposure and lack of confidence. Innovative collaborative approaches are required to prepare NAs to care for seniors.MethodsA 2009 collaboration between a NH group and a community college resulted in the Living Classroom (LC), a collaborative approach to integrated learning where NA students, college faculty, NH teams, residents, and families engage in a culture of learning. This approach situates the learner within the NH where knowledge, team dynamics, relationships, behaviours, and inter-professional (IP) practice are modelled.ResultsAs of today, over 300 NA students have successfully completed this program. NA students indicate high satisfaction with the LC and have an increased intention to seek employment in NHs. Faculty, NH teams, residents, and families have increased positive beliefs towards educating students in a NH.ConclusionThe LC is an effective learning approach with a positive and high impact learning experience for all. The LC is instrumental in contributing to a capable workforce caring for seniors.

Exploring the need for an expertise centre for challenging behaviour

In a case study (N=1) a 78-year-old woman of Indonesian origin was referred for admission to the psychiatric hospital because there were increasing behavioural problems in the nursing home where she was staying. The challenging behaviour consisted of screaming; name calling, pinching, hitting and throwing food. The multidisciplinary team in the nursing home did not cope with the behaviour of the patient. This patient has an extensive history in psychiatry; she was diagnosed with bipolar disorder, anger management disorder and cognitive impairment. Because of cognitive impairment the patient lived in a nursing home because her husband was no longer able to care for her because of his own health problems. The medical team of the nursing home wanted her transfer to GGz centraal with the purpose to treat her provocative behaviour and to lead her to a permanent place to live in a setting appropriate to her problems. Also, the family of the patient supported this. They were very dissatisfied with the care offered in the nursing home. They indicated that they were very overburdened by the challenging behaviour of this patient in the nursing home. They also said that they felt that the nurses tried to solve the behavioural problems themselves without enlisting the help of experts in psychiatry. The patient was admitted to the geriatric psychiatry ward for a multidisciplinary evaluation of condition and challenging behaviour. Through the efforts of the team and the involvement of the family it was clear what causes the challenging behaviour and the team members were able to gradually work on the provocative behaviour of the patient. Most of the causes were related to traumatic experiences in the past. Small simple interventions led to a better quality of life for the patient and the team could discharge her to the nursing home with a clear treatment and supervision plan for the carers. The mental health care management organization came to the aforementioned case study with the question of whether the author wanted to deepen more on this subject and wanted to do research on challenging behaviour in older adults with severe mental illness and cognitive comorbidity. This subject is especially important because at the same time the government decided that the long-term beds must be decreased in psychiatry. Many elderly patients who may have lived most of their lives in the long-term psychiatric wards are being transferred to nursing homes, which lead to problems in the provision of care for these patients. The author claims an expertise centre could provide the solution. The expertise centre challenging behaviour aims to diagnose the possible causes of challenging behaviour and investigate what interventions can be effective. As a theoretical basis it uses the Neuman Systems Model. This nursing model can be used both as a theoretical framework, based on a systems thinking perspective, as well as on a methodical approach to explore nursing problems. Based on this case study an expertise centre for challenging behaviour will be developed in which a multidisciplinary team consisting of a psychiatrist, a nurse practitioner and a nurse will visit the nursing home team members and talk with the patient if possible and his or her family. This team will also focus on the interaction between the caregivers and the patient. The hypothesis of the author is that these efforts will ultimately lead to a better quality of life, fewer readmissions in a psychiatric hospital and a higher satisfaction with the family or directly involved healthcare professionals with the patient. In a next study the patient outcomes of the expertise centre will be investigated as well as the cost-benefits.

Engaged customers as job resources or demands for frontline employees?

PurposeThis paper proposes and empirically tests a theoretical model on how different customer engagement behaviors (CEBs), such as giving feedback and helping other customers, affect the role stress–job strain relationship among frontline employees.Design/methodology/approachDrawing from the job demands-resources model, this paper hypothesizes that some CEBs weaken the role stress–job strain relationship among frontline employees, whereas the opposite holds for other CEBs. To test these hypotheses, the study involved a survey among 279 frontline employees in 20 nursing home teams in Belgium.FindingsThe results reveal that the impact of role stress on job strain is stronger when frontline employees notice more helping behaviors among customers and weaker when frontline employees receive more customer feedback or notice that customers spread positive word of mouth about the nursing home.Originality/valueThis research contributes to the customer engagement and frontline employee literature by showing that CEBs can act as both job demands and job resources for frontline employees.

Continuous subcutaneous infusion in palliative care: a review of current practice.

Syringe drivers are widely used in palliative care, and this article reviews the challenges and outstanding questions associated with their use. Misperceptions among the lay public and some health professionals can be addressed by sensitive communication with patients and families and clear thinking in clinical teams concerning the drugs and doses used, particularly in non-malignant disease. Good levels of knowledge concerning syringe driver use has been found among GPs and community nurses, although this is not the case in some nursing home teams. The advantages of newer devices, safety and efficacy of drug combinations, selection of diluent, and management of site reactions are discussed.

Administering anticipatory medications in end-of-life care: A qualitative study of nursing practice in the community and in nursing homes

Background: In the United Kingdom, an approach to improving end-of-life care has been the introduction of ‘just in case’ or ‘anticipatory’ medications. Nurses are often responsible for deciding when to use anticipatory medications, but little is known about their experiences. Aim: To examine nurses’ decisions, aims and concerns when using anticipatory medications. Design: An ethnographic study in two UK regions, using observations and interviews with nurses working in community and nursing home teams (n = 8). Findings: Observations (n = 83) and interviews (n = 61) with community nurses. Nurses identified four ‘conditions’ that needed to be established before they implemented anticipatory medications: (1) irreversibility; (2) inability to take oral medication; (3) where the patient was able, they should consent and (4) decision had to be independent of demands or requests from patient’s relatives. By using anticipation medications, nurses sought to enable patients to be ‘comfortable and settled’ by provision of gradual relief of symptoms at the lowest dose possible. They aimed to respond quickly to needs, seeking to avoid hospital admission or medical call-out, while adhering to local prescribing policies. Worries included distinguishing between pain and agitation, balancing risks of under- and over-medication and the possibility of hastening death. Conclusion: Nurses take a leading role in the administration of anticipatory medications. Nurses apply consideration and caution to the administration of anticipatory medications but some experience emotional burden. Education, training and experience played a role in the nurses’ confidence and should continue to be central to efforts to improving the quality of palliative care in the community and nursing homes.

The Physician's Role in Patients' Nursing Home Care

More than 1.5 million adults live in US nursing homes, and approximately 30% of individuals in the United States will die with a nursing home as their last place of residence. Physicians play a pivotal role in the rehabilitation, complex medical care, and end-of-life care of this frail and vulnerable population. The reasons for admission are multifactorial and a comprehensive care plan based on the Minimum Data Set guides the multidisciplinary nursing home team in the care of the patient and provides assessments of the quality of care provided. Using the cases of 2 patients with different experiences, we describe the physician's role in planning for admission, participating as a team member in the ongoing assessment and care in the nursing home, and guiding care at the end of life. The increasing population of older adults has also promoted community-based and residential alternatives to traditional nursing homes. The future of long-term care will include additional challenges and rich innovations in services and options for older adults.

A multidisciplinary approach to improve drug therapy in nursing homes

Management of drug therapy in nursing home patients is challenging due to complex health problems, use of multiple medications, and age-related changes in pharmacokinetics and pharmacodynamics. The objective of this study was, first, to examine the effect of systematic medication reviews conducted by multidisciplinary nursing home teams on prescribing quality and, second, to evaluate if drug therapy changes were maintained over time. Patients in a large nursing home in Oslo, Norway, were prospectively followed during a 1.5-year period. Systematic comprehensive medication reviews were carried out and the identified drug-related problems (DRPs) were discussed at multidisciplinary team meetings. After 3 months, the patients’ drug regimens were reviewed again to evaluate if drug therapy changes were maintained. Altogether, 93 patients were included (89% women, mean age 87 years). In total, 234 DRPs were identified in 82 patients, and 151 drug therapy changes were performed in 73 patients. The most common DRPs were ‘drug treatment without a clear indication’ (37% of all DRPs) and ‘treatment with an inappropriate drug’ (20%). After 3 months, 85 patients (91%) were available for follow-up. In these patients, 133 (88%) of the drug therapy changes were maintained, and the mean number of DRPs had decreased from 2.6 to 1.0 per patient (P < 0.01). We were able to demonstrate that medication reviews conducted by multidisciplinary teams were effective to improve the quality of drug treatment in nursing home patients by significantly reducing both number of drugs and number of DRPs. The large majority of drug therapy changes were maintained after 3 months.