San Francisco County: Improving the Safety of Sedative-Hypnotic Prescribing

1. San Francisco County: Improving the Safety of Sedative-Hypnotic Prescribing Michelle Geier, PharmD Psychiatric and Substance Use Disorders Clinical Pharmacist Behavioral Health Services, San Francisco Health Network

2. Disclosures • The presenter has no conflicts of interest

4. Creating a Performance Improvement Project

5. Jan 2014: BHS decided to take on Safer Sedative-Hypnotics as a Performance Improvement Project • Large population effected • The potential for unsafe sedative-hypnotics prescribing exists for all BHS consumers • Increased patient safety • Consistent with the Wellness and Recovery Model • Cognitive dysfunction and impaired memory are barriers for client’s wellness and recovery • Consumer demand • Consumers request both providers and clients receive more education on sedative-hypnotics

6. UNSAFE SEDATIVE-HYPNOTIC PRESCRIBING ROOT CAUSE ANALYSIS NON-MEDICAL PROVIDERS PATIENTS PRESCRIBERS Home environment not conducive for sleep Lack of education re: risks Lack of commitment or experience with non-pharmacologic treatment Attachment/preference to current regimen Inherited patient on regimen Lack of education re: risks Policy may limit appropriate treatment Benzodiazepine use disorder UNSAFE SEDATIVE- HYPNOTIC RX Poor coordination between care settings Medical record not integrated across system No policy requiring risk assessment Lack of support for non-pharmacologic treatment No policy requiring documentation for ongoing use Cumbersome to obtain CURES access Poor documentation of rationale for ongoing use POLICIES PROCEDURES EQUIPMENT

7. Study Question If we formulate and implement Safer Prescribing of Sedative-Hypnotic Guidelines, then we will reduce the long-term use of sedative-hypnotics?

8. Study Population Includes all adults (18+) with billed services in the BHS electronic health record • Total of 11,921 clients in 2012-2013 • Did not include <18 years – sedative-hypnotics accounted for <1% of total number of prescriptions in this group in FY 2013-2014 • Excluded clients who only receive services in locations where they do not use the BHS prescribing software • Excluded inpatient, crisis stabilization, long-term care, private provider network Also Evaluated High Risk Subpopulations: • Older adults (age 60+): 2752 clients • Methadone maintenance: 542 clients

9. Study Indicator Indicator: Number of chronic (≥60 days) prescriptions during a quarter for sedative-hypnotics • Reasoning: • Decreasing sedative-hypnotic use could improve health status and functional status of our clients • Sedative-hypnotic prescribing was identified as a problem in our system • Did not include short-term use due to treatment guideline recommendations • Considered number of sedative-hypnotics related deaths • Due to low incidence it is difficult to detect change, therefore not selected

10. Baseline Data for BHS – 2012-2013

11. Baseline Data – 2012-2013 * Determined by a mean of the 8 quarters in 2012-2013

12. Implementation

13. Implementation Challenges • Technical • Staff • Client

14. Technical Challenges • Access to CURES and interpreting CURES reports • Methadone maintenance not on CURES reports • Distributing guideline to staff • Educating staff about the new guideline • Do we have adequate staff to provide non-pharmacologic interventions?

15. Staff Challenges • “I’ve been told we have to take you off this medication…by our very mean pharmacist” • Caught in the middle of administrative goals and patient demands • Prescriber hands feeling tied with few pharmacologic options • Difficult to tolerate patient push-back • Time concerns

17. Patient Challenges • Lack of education about risks • Client fears of change • Denial of risk – “This will never happen to me” • “I take my medicine as prescribed”

18. Clinic Implementation

19. Clinic Staff and Administrative Implementation • Prescriber meeting to discuss cases and peer review • Clients taking concomitant opioids or over 60 years • Challenging cases • Any new, changed, or requested sedative-hypnotic • Frequency: every 1 – 4 weeks • Internally auditing and following medication list, doses, and ages for all clients on sedative-hypnotics

20. Patient Education • Welcome letter for new clients that informs them of Behavioral Health’s status on sedative-hypnotics • Safety concerns and long-term treatment is not recommended • Offering EMPOWER handout to those asking about sedative-hypnotics • Sedative-hypnotic patient agreement • Reviews risks • Sets expectations for both prescriber and patient • Patient education visits with clinical pharmacist to discuss risks and benefits • Consistent message across medical team

21. 1 1/2 Years of Follow-up Data

22. Pre- and Post-Implementation Summary 1. All Medical Staff Meeting ReviewingMMT Death Data 2. Registering Medical Staff with CURES 3. Form MUIC Subcommittee to Create a Sedative-Hypnotic Guideline Disseminate and Implement the Sedative-Hypnotic Guideline DisseminateGuideline to SFGH psychiatry

23. BHS Plans for 2015 • Continue quarterly measurements and analysis by MUIC • Joint education with primary care and mental health providers • Develop a non-pharmacologic treatment of insomnia toolkit • Sleep hygiene patient education handouts • Focus on older adults • Patient education materials • Assist providers with identifying patients • Shift to non-medication treatments and team approach

24. Questions?