Investigators at the Atlanta site of the Birmingham/Atlanta VA Geriatric Research and Education Clinical Center (GRECC) developed the Integrated Management and Polypharmacy Review of Vulnerable Elders (IMPROVE) clinical demonstration project to enhance medication management and quality of prescribing for vulnerable older veterans. Poor quality prescribing in older adults is common and can result in adverse drug reactions (ADRs); increased emergency department, hospital, and primary care provider (PCP) use; and death. The ADRs alone, which are strongly correlated with multiple medication use, account for at least 10% of hospitalizations in older persons.1
Many factors contributing to poor quality prescribing in older persons include time constraints on health professionals, multiple providers, patient-driven prescribing, patients with low health literacy, and frequent transitions in care between home, hospital, and postacute care. Older veterans may be harmed by taking medications with no clear benefit, duplication of therapy, and omission of beneficial medications. Prescribing medications with known high risk for ADRs, inadequate monitoring, and limited patient education on how and why to take a medication can further increase the risk for adverse outcomes. Prescribing for multimorbid older veterans requires comprehensive, individualized care plans that take into account patients’ goals of care and quality of life, as well as evidence-based practice standards.
Clinical trials have repeatedly shown that individualized pharmacy review can reduce polypharmacy in older patients. Positive outcomes have included reduced ADRs, improved measures of prescribing quality, appropriate medication use, compliance with care recommendations, and reduction in the total number of medications.2-5 Optimal use of medications is achieved when a pharmacist works with other care team members to implement and oversee a care plan, as opposed to each provider working alone.2,5
In 2011, the VHA Geriatrics Pharmacy Taskforce recommended that facilities offer “individualized pharmacy review for high-risk patients on multiple medications.”6 This recommendation was in line with the increasingly integrated role of the clinical pharmacist in the patient aligned care team (PACT) and the recent requirement that Medicare Part D medication therapy management programs offer this service to select patients with chronic disease.
The IMPROVE Model
Given the high and growing numbers of older veterans enrolled in VA primary care who are at risk for ADRs, the Atlanta VA IMPROVE team implemented a GRECC-funded clinical demonstration project. The project supported the VA’s focus on PACTs in combination with existing best practice standards to improve medication management in high-risk older veterans. The Emory University Institutional Review Board ruled that IMPROVE was a quality improvement project, and therefore was exempt from review and VA research oversight.
For this clinical demonstration, IMPROVE targeted noninstitutionalized veterans aged ≥ 85 years taking 10 or more medications who received care in the VA primary care clinic and used the VA pharmacy for medications. This cohort represented the top 5% of medication users enrolled in the clinic. While age and number of medications are independently associated with increased risk for ADRs, other factors common in this cohort, including higher levels of comorbid disease, frequent care transitions, and cognitive impairment are also associated with higher ADR risk.7The IMPROVE model was designed to promote fully engaged partnerships among veterans, family caregivers, and the PACT with input from all parties in the design of the model. The IMPROVE team conducted individual, qualitative, semistructured interviews with 5 clinical pharmacists, 5 geriatricians, and 1 geriatric nurse practitioner on the challenges faced in the management of medications for older patients, individual needs/barriers to meet these challenges, the clinical pharmacist role in providing recommendations to providers, and attitudes and preferences for team communication.
Challenges discovered included time constraints during clinic visits, a need for joint decision making, and limited competency with principles of health literacy. The IMPROVE team also conducted focus groups with veterans (n = 4) and caregivers (n = 7) to determine medication management needs, values, preferences, and barriers to self-management. Key findings from these sessions included poor recognition of limitations in medication self-management, problems related to health literacy, and misunderstanding the role of the clinical pharmacist.8
Using the information gained from patients, family caregivers, and PACT members, the model was tailored to address concerns. The IMPROVE model engaged a PACT clinical pharmacist skilled in medication management and patient education to perform a face-to-face clinical consult with selected patients and their caregivers.5 Making veterans, families, and PACT members collaborators in IMPROVE’s design helped establish active partnerships that enabled effective execution of the project and promoted sustained culture and system change over time.
High-risk veterans and their caregivers were recruited by letter, followed by a phone call to schedule an appointment for those interested, and a reminder to bring all their medications to the appointment. Twenty-eight male veterans participated in the pilot. The average age was 89 years; 52% were white; 53% had a diagnosis of dementia; 78% reported assistance with medication management; and patients took an average of 16 medications daily. Recruited high-risk veterans and their caregivers were seen in a 1 hour in-person visit with the clinical pharmacist.