For Mark Coggins, medication management is about a lot more than medication. As vice president of pharmacy services and medication management at Diversicare Healthcare Services Inc., a provider of postacute services to patients and residents at seventy-six centers in the United States, he has worked to improve medication management by implementing a cross-disciplinary approach to patient care.
“Whether they’re going to be with us for one week or a year or two years, we try to find ways to get patients on the best medication management that we can so that when they go back out to the community, they have a greater chance of living healthily,” Coggins says.
Among Diversicare’s most successful programs are its de-prescribing initiatives, which focus on reducing or stopping potentially inappropriate medications, including antipsychotics. “Often, medication use in the elderly is a result of a prescribing cascade that occurs when one drug is added to treat the side effects of another medication without recognizing that the original issue was medication related,” Coggins explains. “De-prescribing efforts can improve a patient’s quality of life by reducing polypharmacy, adverse drug events, and medication-related problems ranging from falls to cognitive decline and hospitalizations.”
Through the de-prescribing initiatives, Diversicare reduced its antipsychotic use by nearly 50 percent in six months throughout ten states.
Many of Diversicare’s long-term residents live with dementia, and dementia patients have historically been prescribed antipsychotics to address their behavioral challenges. To so dramatically reduce the antipsychotic prescription rate, Coggins helped initiate a cultural shift at Diversicare, starting with how care providers view patients with dementia. “They have dementia, but let’s not define them by having dementia,” he says. “Let’s remember what their likes and dislikes were when they were younger because those haven’t changed.”
“A cultural approach to medication management describes a best practice for the care of our elderly residents, especially those with dementia,” says Todd King, director of clinical services at Omnicare. “Resident-centered care is a process that allows all members of the interdisciplinary team, including families, to participate in the approach to treatment plans. This approach leads to better outcomes and, from a pharmacy standpoint, more streamlined and appropriate medication regimens.”
Care providers work with family members to learn more about the residents as people, instead of just as patients. They also have increased patient and family interactions at the time of admission to help educate them on what they can expect and learn the family’s goals. “It’s part of our mission or vision as an organization that we’re always striving to exceed our patients’ expectations and to improve outcomes,” he says. “What we’ve done across the board is to take a step back and recognize that we have to include the family and the patients themselves in their care if we’re going to have the ability to enact meaningful change.”
Coggins and his colleagues have also empowered family members to help identify and address medical and behavioral needs. “We do a lot of work with training our families, team members, and prescribers to look at any behavior as a possible unmet need,” Coggins says. Behaviors can indicate pain, discomfort, boredom, or frustration, which are often better addressed through therapy or other non-medication means.
In developing the de-prescribing initiatives, Coggins drew on his seven years of experience at a previous national senior healthcare company, where he launched programs that examined the role of pharmacists in improving medication-related outcomes in nursing homes.
In this previous role, Coggins was nationally recognized for his work to actively integrate board certified geriatric pharmacists (BCGP) within the center’s healthcare team by the Commission for Certification in Geriatric Pharmacy, which awarded him the 2010 Excellence in Geriatric Pharmacy Practice Award. He was also elected to the board of directors for the American Society of Consultant Pharmacists, the professional organization for senior care pharmacists, which he served on for four years. He continues this educational work as a writer for Today’s Geriatric Medicine, where he writes articles on issues that affect the aging population.
Diversicare’s de-prescribing initiatives begin with senior leadership and the Clinical Practice Committee, which is led by Diversicare’s senior vice president of clinical services, along with content experts, including Coggins, the COO, the national medical director, and the vice president of therapy services. The content experts facilitate the delivery of messaging to their respective disciplines to gain necessary support and momentum for successful program implementation; Coggins promotes the message to consultant pharmacists; the senior vice president of clinical services discusses with nurses; the national medical director includes physicians and prescribers, while the CEO and COO solicit support from operational leadership.
“We bring our bedside care expert leaders together and then roll out programs, gaining buy-in from each discipline,” Coggins says. “From the top down, everybody is on board with doing what’s right for the patient and putting them first.”
Although the leaders spread the message using the traditional framework of distinct care professions, Coggins and his colleagues emphasize transdisciplinary professionalism, which breaks down the barriers among different functions and emphasizes every team member’s responsibility to total patient care. Traditionally, pharmacists, physicians, nurses, therapists, and other care providers each emphasized their own discipline’s approach to care. “An individual profession can be doing things that they believe is in the best interest of the patient, but it’s siloed,” Coggins says. “With transdisciplinary professionalism, regardless of which discipline you are in, you’re holding each other accountable for the actions and behaviors of each team member.”
To further break down traditional barriers, Diversicare instituted the Care Alignment Program to focus on patient-specific solutions for high-risk patients, with clinical leaders within the nursing center collaborating as a team at the patient bedside instead of working individually within their disciplines. “There is plenty of time for the doctor to be the doctor. We don’t take away what they’re inherently the expert on,” he says. “But we instill in everybody that there’s this mutual respect that has to occur if we’re going to change anything that we’re doing.”
Challenging the status quo is no easy prospect, but the benefits for patients outweigh the challenges. “People don’t necessarily like you stepping into what’s traditionally been thought of as their area of expertise,” he says. “You have to have thick skin to implement change.”
Photo by Tricia Bartlett