Addressing High Risk Medications

[dropcap color=”white,” background=”black” style=”rectangle” size=”big”]O[/dropcap]ne of the most challenging issues facing pharmacist is what to do about high risk medications. Patients are often reluctant to stop using high risk medications and doctors are frustrated with a lack of options. All the while, pharmacies are being evaluated by Medicare since the adoption of a performance measure that looks at the number of patients on high risk medications. Approaching high risks mediation use is a lot like approaching a grizzly bear; you don’t know until after you approach it if it is a circus bear that juggles, or a wild, angry, and hungry bear.

Given the uncertainty involved, the approach taken is very important. While there is not one right way to approach high risk medication use with either the patient or the prescriber, this article will outline some guidances for pharmacists to consider when deciding how to initiate the conversation.

 Preparation

Before venturing into the unknown, a few first steps are very helpful

1. Determine which prescribers are writing the larger share of high risk medications. This may require reports or other data extraction from the Pharmacy Management Software.  Knowing who to deal with  ahead of time allows one to better prepare.
2. Meet with select prescribers to discuss the issues. The goal here is to understand the issues and concerns the prescribers have about these medications. Be sure describe the Medicare Quality Measures and how both pharmacies and prescribers ratings are effected. Determine the level of engagement for these prescribers.
3. Prepare a standard procedure. When approaching a difficult task, it helps for every member of the pharmacy team to be on the same page. Standard procedures, including standardized phrasing for notes sent to prescribers and talking points when discussing the issues with patients or family members.
4. Start small. Working with the prescribers involved earlier, identify a small pool of representative patients to approach.
5. Being proactive.  Resolving a drug therapy problem before it becomes a problem is a good approach for high risk medications.  In other words, by performing continuous medication monitoring and identifying high risk medications before dispensing the first fill can be a better approach.
6. Be an evidence-based.  There is plenty of literature that discusses the risks of high risk medication especially in older patients (>65 years old).  Pharmacists have a more convincing argument when they know literature and can discuss the risks with patents and prescribers.   But how this information is communicated can impact how it is accepted by others.
7. Be an interventionist.  What is meant here is that if the pharmacist identifies a patient on a high-risk medication, then it is important that the pharmacist take action to try to resolve this drug therapy issue.

Intervening with the patient

As health care providers, pharmacists sometimes get the cart ahead of the horse. Before making any recommendation to the patient, it is important to..

1. Explain why the pharmacy is looking at the medications. Speak in terms of safety risk / benefit and overall outcomes.
2. Strive to understand the patient’s situation. It is tempting to simply state that one should not be taking a given medication due to overall risk. Instead, ask questions to help identify how important this medication is to the patient and how they feel about the associated risk(s).
3. Involve the patient in the decision on how to proceed. As a pharmacist, don’t forget that it is the patient that will have to deal with the consequences of any change in their drug therapy. Offer several options on how to proceed and seek imput from the patient. Success is more likely if the patient is involved in the decision.
4. Initiate the plan. Decisions at this point can run the entire spectrum from the patient being unwilling to considering any changes to a willingness to try a variety of options. How to proceed from this point will hinge on your conversations with the prescriber(s) earlier.
5. Document the plan. It is is unrealistic to expect a pharmacy to drop high risk medication to zero. Even a failure to effect a change, if documented, is a success.
6. Follow-up. Do not forget to schedule follow-up with the patient. This is an especially important action item if any changes were made. This should also be documented in the patient record. If no changes were made, follow-up should still be scheduled for the purpose of revisiting the discussion at a later date. Six months or 1 year are reasonable intervals for this type of follow-up.

Ultimately, patient willingness to consider changes depends on a number of factors. For patients that are resistant to changes, follow-up at a later date is important. With time, the pharmacist’s understanding of the patient’s motivations will increase, leading to new opportunities to change behavior.