To maximize the benefit of the session, the pharmacist was provided with several tools to assist in a systematic evaluation of medication management concerns and quality of prescribing. Tools included a quick reference card citing potentially inappropriate medications (PIMs) per the published 2012 Beers Criteria and a reference for potentially beneficial medications based on the START-STOPP criteria.9,10
A Computerized Patient Record System template was developed to guide the pharmacist visit. The template included medication reconciliation, a systematic review of all medications to verify indication and check for redundancies, drug interactions, PIMs, and proper therapeutic monitoring. The template also included assessments for level of medication assistance available, goals of care, health literacy, and barriers to adherence.
A collaborative review of the medication regimen was conducted with the veteran, caregiver, and pharmacist, resulting in individualized recommendations, education, strategies, and tools to improve the quality and safety of the medication regimen as well as patient adherence. When necessary, pill boxes, illustrated medication schedules, low vision aids, and other adaptive devices were provided.
Communication of recommendations with the PCP occurred by cosignature on the note. Same-day consultation with the PCP was also available for any urgent concerns or significant changes to the regimen. At the discretion of the pharmacist, a face-to-face follow-up visit with the pharmacist or a follow-up phone call was conducted.
Results
Both qualitative and quantitative outcomes measures were used to evaluate the IMPROVE model. Semi-structured postpilot interviews with PCPs showed that the model had high satisfaction, acceptability, and feasibility. Providers reported that the model helped them and their patients in an area that takes considerable time (medication review and education) and is not always feasible in a short clinic visit. Providers were willing to accept pharmacist recommendations, which was likely fostered by pre-intervention strategies to keep communication open about proposed medication changes. In a survey, 93% of patients and caregivers found the IMPROVE model helpful; 100% recommended the clinic to others.
Objective measures found 79% of patients in the pilot had at least 1 medication discontinued, 75% had ≥ 1 dosing or timing adjustments made, and PIMs were reduced 14%. Comparing the 6-month period before the pilot and the 6 months after, pharmacy cost savings averaged $64 per veteran per month. Health care use showed a decreasing trend in phone calls and visits to the PCP.7 Cost savings were comparable or greater than those previously reported for similar interventions.4
Conclusions
The results of the IMPROVE pilot suggest that an integrated model involving both pharmacists and PCPs in managing medications and empowering the patient and family caregivers as stakeholders in their own care can lead to improved quality of medication management and cost savings. Based on the success of the pilot, the IMPROVE model received VA Office of Rural Health funding to translate this model to target rural older veterans in community based outpatient clinics.
The success of the IMPROVE model was undoubtedly enhanced by engaged PACT members at the pilot site and a clinical pharmacist who championed the model. The effort involved in recruiting, scheduling, and assessing participants may limit generalizability to settings without such a champion and without dedicated time available with a pharmacist. Determining which groups of older veterans benefit most from individualized medication management and optimal methods to translate the program to other primary care settings are ongoing endeavors for the Atlanta GRECC IMPROVE team.
Acknowledgments
This project was supported by a VA Transformation-21 grant awarded through the Office of Geriatrics and Extended Care. The authors thank Christine Jasien, MS; for data management, Aaron Bozzorg, MS; for interview transcription, Joette Lowe, PharmD; for general consultation; and the VISN 7 leadership for their support.
