Nurse practitioner-led care transitions program: medication management from skilled nursing facility to home

J Nurse Pract. 2020;16(8):560-563.

A large number of patients transitioning from skilled nursing facilities to home experience adverse events. Medication events during transitions of care are common, often resulting in adverse patient outcomes. The researchers examined the impact of a nurse practitioner-led care transitions program on patient outcomes.2 They found that medication reconciliation is an integral part of transitional care to help reduce adverse events.

Commentary by Dr. Baker:


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This article highlights the need for a care transitions program for patients who are being transferred from skilled nursing facilities (SNF) to the community. Patients are at increased risk for negative health outcomes when transitioning between care levels. Older adults with multiple comorbidities and medications are particularly vulnerable during episodes of care transitions.

Patients transitioning from SNF often require changes in their health care providers and dependence on informal caregivers to meet their basic activities of daily living, including assistance with medication administration. An estimated 40% of SNF patients receive at least 9 medications daily, a staggering number of medications to administer correctly when a patient returns home.

Transition of care has not been extensively researched in relation to SNFs. Patients discharged from SNFs among the frailest patients within the health care system, requiring extensive input from health care providers. One study revealed that within 3 months of discharge from an SNF, 20% of patients will present to an emergency department, 30% will be rehospitalized, and 8% will die.

The Care Transitions Program (CTP) at Mayo Clinic identifies patients who are at increased risk for rehospitalization. Patients are offered CTP services during the SNF discharge process if they are at least 60 years of age and are being discharged into the community. A nurse practitioner visits within 72 hours of SNF discharge. The visit focuses on medication reconciliation, safety and mobility, contingency planning, community resources, and advanced care planning. Forty patients were enrolled in the pilot and experienced a lower 30-day rehospitalization rate.

Association between psychotropic drug use and prescription opioid use among older adults

Geriatr Nurs. 2020;41(6):776-781.

The study examined the association between opioid and psychotropic medication use among older adults.3 The study included a sample of 203,750 participants enrolled in Pennsylvania’s Pharmaceutical Assistance Contract for the Elderly program, which is available to residents 65 years of age or older with low or moderate income. The authors found that prescription opioid use and high dosage opioid use were significantly associated with anxiolytic/sedative/hypnotic use and antidepressant use in this populations. Additionally, the results suggest that older adults who use psychotropic drugs are at greater risk for prescription opioid use and high dosage use.

Commentary by Dr. Baker:

Opioids are frequently prescribed to older adults for chronic pain management. The Centers for Disease Control and Prevention recommends avoiding opioid at dosages more than 90 morphine milligram equivalents (MME) daily for chronic pain due to adverse effects including falls, respiratory complications, and accidental overdose. In 2016, approximately 500,000 Medicare Part D beneficiaries received high dosages of opioids, averaging more than 120 MME daily for at least 3 months.

Concomitant opioid use with psychotropic medications can further impair an older adult’s well-being. Some studies have suggested that chronic pain or opioid drug use significantly predicts mental illnesses, often resulting in the need for psychotropic medications. When prescribed together, opioid and psychotropic medications increase the risk for falls, fractures, and emergency department visits.

The study consisted of 203,750 participants enrolled in Pennsylvania’s Pharmaceutical Assistance Contract for the Elderly program, which is available to residents 65 years of age or older with low or moderate income. Data were obtained from January to December 2017. The psychotropic drugs were grouped according to the American Hospital Formulary Service classification: anxiolytics/sedatives/hypnotics, antidepressants, and antipsychotics. Each group was evaluated separately.

Statistical analyses revealed opioid prescription users were more likely to be aged 65 to 69 years (P <.0001), White (P <.0001), divorced or married but living separately (P =.0010), and living in rental housing (P <.0001). Opioid prescription users were also more likely to use anxiolytics/sedatives/hypnotics (P <.0001), antidepressants (P <.0001), and antipsychotics (P <.0001).

To mitigate negative health outcomes, providers should carefully screen older adults before prescribing opioid and psychotropic medications.

References

  1. Abdeljalil AB, de Mauleon A, Baziard M, Vellas B, Lapeyre-Mestre M, Soto, M. Antidepressant use and progression of mild to moderate Alzheimer’s Disease: results from the European ICTUS cohort. J Am Med Dir Assoc. 2021;22(2):433-439. doi:10.1016/j.jamda.2020.06.028
  2. Mohammed N, DiTommaso M, Jacobsen S. Nurse practitioner-led care transitions program: medication management from skilled nursing facility to home. J Nurse Pract. 2020;16(8):560-563. doi:org/10.1016/j.nurpra.2020.05.017
  3. Khan SR, Heller DA, Latty LL, Cadieus RJ, LaSure M, Brown TV. Association between psychotropic drug use and prescription opioid use among older adults. Geriatr Nurs. 2020;41(6):776-781. doi:10.1016/j.gerinurse.2020.04.017

This article originally appeared on Clinical Advisor