PHARMACOLOGICAL INTERVENTION IN LATE LIFE (PILL) PROJECT

1. Background

   The transition from hospital to home is a critical time complicated by numerous medicines, drug toxicities, regimen changes, and discrepancies. The Pharmacological Intervention in Late Life (PILL) project was developed to enhance medication safety in older, cognitively impaired veterans during this transition. The goal of PILL is to keep patients functioning longer at home after a hospital stay by use of medication reviews, telephone follow-up, and a collaborative physician-pharmacist medication clinic. Team efforts have also improved discharge education materials via production of two patient education videos that are currently rolling out on inpatient wards. PILL is supported by a T21 grant administered by the Office of Geriatrics and Extended Care to prevent long term institutionalization in high-risk veterans.

2. Objectives

   The goal of the PILL project is to reduce morbidity and keep high-risk patients functioning longer at home after a hospital stay by providing medication follow-up and ensuring safe medicine use.

3. Process

   In this quality improvement project, patients ≥65 years old, with evidence of cognitive impairment, who were discharged home from the Boston VA, were eligible for PILL follow-up. These veterans received a geriatric medication review and telephone call by a pharmacist. PILL clinic appointments were scheduled in complicated cases. PILL clinic tasks included medication reconciliation (with patient's actual medications), drug evaluation, patient education, and medication reduction.

   Pharmacist follow-up includes evaluation of regimen for Pharmaceutical Care Issues:

   1. Potentially inappropriate medications
      • Contraindication
      • Medications that may impact cognition (i.e. anticholinergics)
      • Beer's Criteria
      • Drug without indication
      • Ineffective agent
      • Dosing (i.e. renal, hepatic dose adjustments)
      • Allergy/intolerance
   2. Interactions (drug-drug, drug-disease)
   3. Adverse drug events
   4. Regimen complexity and adherence
      • Calculate Medication Complexity Score
   5. Medication Discrepancies
      • Identify and clarify discrepancies
      • Contact providers as needed

   In addition to time spent during actual phone-call, the pharmacist must also spend approximately 30-60 minutes of time to review medication history, outpatient and inpatient progress notes, hospital course, and critically evaluate drug regimen.

4. Impact on Veterans

   Elderly patients consume more medicines than any other cohort and are at increased risk for adverse drug events. The PILL medication review and phone intervention proactively targets post discharge veterans to address medication errors and discrepancies and provide education. Many patients, notably those with multiple comorbidities, have experienced drugs being added to their regimens over time. However, providers may not assess the need to subtract drugs. In PILL clinic, our team partners with patients and evaluates medication lists for potential streamlining and reduction. These processes enhance medication safety for veterans. Medication reconciliation is the core of the PILL project which is in line with VA patient care goals.

5. Lessons Learned

   Elders with cognitive impairment were discharged home with many medications and were often confused about medication changes. In addition, medication discrepancies in this population were frighteningly common. This confirms our belief that these patients are at high risk for returning to acute care. Post discharge services, such as the PILL project, are valuable safety nets and can prevent readmissions. The interdisciplinary approach used in PILL is ideal for clarifying medication discrepancies, as well as evaluating and optimizing regimens.

6. Outcome

   In our clinical experiences, it was recognized that at-risk elders were discharged home from the hospital with many medications. These patients were often confused about regimen changes. In addition, medication discrepancies in this population were frighteningly common. By quantifying the magnitude of these clinical observations, we hope to confirm that these patients are at high risk for returning to acute care. Post discharge services, such as the PILL project, are valuable safety nets and can prevent post hospitalization utilization which is optimal for both the patient and the system. The interdisciplinary approach used in PILL is ideal for clarifying medication discrepancies, as well as evaluating and optimizing regimens.