This article is sponsored by Optum. This article is based on a discussion with Michelle Graham, director of Clinical Pharmacy Patient Care for Optum Home and Community. The conversation took place on April 20, 2023 during the Skilled Nursing News Clinical Conference. The article below has been edited for length and clarity.
Skilled Nursing News: Michelle, it would be great if you could introduce yourself, talk a little about your role and your team at Optum.
Michelle Graham: I am director of Clinical Pharmacy Patient Care for our Senior Community Care as well as our Senior Living, so assisted living, ISNP, all those members we help take care of. I have a team of clinical pharmacists all of them are board-certified in various specialties; pharmacotherapy, geriatrics, psychiatry and residency trained. We collaborate with our nurse practitioners who are in the facilities caring for our members every day. We are a support system for them.
SNN: Fall prevention is obviously really important, but can you elaborate a little bit on why it’s important?
Graham: We know CDC says every year 36 million of our geriatric population falls. That equates to about 32,000 deaths per year. Falling is the number one because of hip fracture, which we know has a high one-year mortality rate, as well as traumatic brain injury. When our elderly population go to the hospital, it’s most likely because of a fall. It changes their quality of life and it’s detrimental to families and the facility. We really focus hard on trying to keep our members safe and doing what we can to prevent those falls.
SNN: How do you identify members who are at high risk for falls?
Graham: We target what we believe to be the highest risk for falls. We look at members who have low blood pressure, so systolic blood pressure less than 120 or they have orthostatic hypotension as a problem. We also look at low A1Cs. Anyone with an A1C less than 6.5 who has the potential for hypoglycemia, we consider them at high risk for falls as well.
We also target members who are over the age of 65 and those that are on at least one, CNS medication or central nervous system-acting medication. These include antipsychotics, benzodiazepines, and opioids. All of these medications can increase the risk of falls. We target those members as our highest-fall-risk population.
SNN: You brought up those medications. Can you just build on that a little bit and talk about the role of medications in contributing to falls?
Graham: We know there’s modifiable risk factors for falls such as gait, proper shoe wear, having vision impairment, things that we can correct. There’s also non-modifiable risk factors like disease states, such as Multiple Sclerosis, Parkinson’s disease, but medication is actually a very modifiable risk factor for falls. We know that medications like these central nervous system-acting medications, have side effects. They make the member sleepy, dizzy, or even orthostatic, which is the number one reason for falling.
One of the things that happens as you age is the way you metabolize medications changes. Your kidney function decreases, your hepatic function decreases, and those changes can cause you to retain drugs longer and have increased side effects from medications. We’re very vigilant about what medications can do in our older population.
SNN: Can you talk a little about the collaboration between the Optum advanced practice clinician and the pharmacist and how that works?
Graham: We collaborate on many levels. With the falls work that we’re doing, we provide our Optum nurse practitioners a full medication review. We review the member in our electronic medical record since we are not right there with the patient. We have an objective view of that patient that our nurse practitioners have documented. We look for things like trends in blood pressure, trends in A1Cs. We look to see the member’s fasting glucose levels. Then we review every medication specifically looking to see if the medication has an indication, if there are extra medications that have been on the profile for many years that have not been looked at that perhaps have just lingered on?
We’re providing them a full document that basically step by step gives them the recommendations for deprescribing those medications or reducing those medications, how to follow up everything, and what they need to do to safely discontinue that medication in that member.
SNN: Can you speak a little bit to the facility level about some of the benefits that come from this fall prevention approach?
Graham: Optum already has a successful program. What the pharmacists are is an ally in prescribing. We help our nurse practitioners, with the information that we provide them, to be able to have a really engaging conversation with the medical staff at the facility using the medication recommendations that we provide. We know that these medications pose a risk. The Mega Rule was passed several years ago and there’s a lot of eyes on antipsychotic use within facilities. It’s prescribed primarily for behaviors and dementia, which if you’ve read the guidelines, should be reevaluated every three months, which we know is not always happening. It’s also used a lot for insomnia and there’s no clinical indication for insomnia. Using sleep hygeine and other modalities is important as we don’t want to always have to turn to medications that have more risk than they do benefit in these members.
SNN: I guess I’m curious in terms of getting people off those medications, obviously, they’re on them for a reason. Are there alternative non-pharmacological pathways to treat those conditions or can you speak a little bit to what it takes to actually either get them off the medication? Does the medication change? What are the solutions here?
Graham: It’s an interesting point. When we say they’re on them for a reason, a lot of times these members fall into what you call a prescribing cascade. We start a medication, there’s a side effect to a medication, we deem that side effect a new clinical condition, we give them another medication, there’s another side effect. A majority of these members end up with 20 plus medications on their medication profile, none of which are any longer needed.
A lot of the medications that these members come in on have been on there for 10 or 15 years and they’ve become a comfort blanket to that member. Really what we’re doing is taking that member where they are at that moment and saying these are the medications that will benefit the member and these are the medications that no longer are benefiting them, but causing them harm, and having that conversation with not only the nurse practitioner but sometimes with the families as well.
SNN: Can you speak to the addition of clinical pharmacists and how that enhances the overall Optum model?
Graham: We already have our nurse practitioner hovering over the member, but in the background, we’re providing them prescribing/deprescribing support. The nurse practitioners submit drug information questions. They’re able to have immediate contact with us at any time of the day. If they are treating an infection and they have some questions about antibiotic use based on the members’ lab values, we’re there to support that, answer those questions. We’re an immediate resource.
They can meet with a pharmacist at any time. They can also submit to have a member reviewed by a pharmacist post-fall. We all know that’s very important when someone comes out of the facility or the hospital to say, “Let’s look and see what caused that fall. What do we need to do?” We’re there for that as well. It’s a constant collaboration where we work through any issues with the members that they have.
SNN: Are there other ways that the clinical pharmacists collaborate with the Optum Advanced Practice clinicians?
Graham: We have really ventured into many high-risk situations with prescribing for the members. We’re looking at anticoagulants right now. Members who are on two or more anticoagulants, we know that they are at an increased risk, for a GI bleed. GI bleed is a very costly hospitalization, resulting in a lot of issues for the member. We are looking at, are these anticoagulants still necessary? Do they still need to be on both? If they do need to be on them, we ask are they on a proton pump inhibitor to prevent GI bleed? We’re also looking at NSAIDs and anticoagulants and reducing risk around this medication combination.
We know that when a member in a nursing home started on a Benzodiazepine, if it is continued to be prescribed more than two refills, that they’re have a high chance of the medication remaining on their medication profile long term. It’s very hard to deprescribe a Benzodiazepine. It’s a medication with l withdrawal symptoms if stopped to quickly. We’re starting to intervene after the first fill, “Here’s some alternatives. We see you’re using this for sleep.” Let’s talk about some alternatives that we can use for sleep that are safer for that member.”
SNN: I think you’ve spoken to a lot of the ways that the Optum team is working with pharmacists and working with the facility. That’s a lot of people. Can you maybe speak to, when you come into a facility for the first time, how do you bring the team together and get buy-in and drive toward these outcomes that you’re looking for?
Graham: When we have new members enroll into our program, we’re available for new enrollee medication reviews. We look at the number of medications that a new member comes into the facility on. If they’re on more than nine medications, our pharmacists are reviewing them, getting them down to nine medications and they’re coming in with that instead of the facility having to start to try to do that deprescribing themselves. We are trying to get our Optum members as safe as they can be from the moment they touch our plan.
SNN: Then even beyond Optum members, are you seeing this approach have wider implications at the facility overall in terms of they’re just a general approach to risk management around falls?
Graham: We are. We started our work around medication adherence. We work very hard to make sure that our members get our medications. It’s something that’s very important to us at Optum. We’ve improved our adherence rate from about 82% amongst our members to about 92% now. When you work at Optum, you have a ton of data and so we’re able to track claims, we’re able to know which members are refilling, which ones aren’t.
What we’re finding is we started deprescribing these chronic medications that were no longer needed long ago and we’re seeing that we’re having much more safety around treatment of diabetes and blood pressure early on. Now we’ve just expanded it into the falls work. Optum’s been deprescribing a long time. We’re probably the only pharmacists who actually suggest stopping medications instead of continuing them. We’re big believers and less is more and safety first when it comes to medications.
Optum is committed to making health care work better, leading the way to better experiences, better health, and lower costs. To learn how, visit: https://www.optum.com/.
Companies featured in this article:
