1. S AN F RANCISCO C OUNTY : I MPROVING THE S AFETY OF S EDATIVE -H YPNOTIC P RESCRIBING Michelle Geier, PharmD Psychiatric and Substance Use Disorders Clinical Pharmacist Behavioral Health Services, San Francisco Health Network

2. D ISCLOSURES The presenter has no conflicts of interest

4. C REATING A P ERFORMANCE I MPROVEMENT P ROJECT

5. J AN 2014: BHS DECIDED TO TAKE ON S AFER S EDATIVE - H YPNOTICS AS A P ERFORMANCE I MPROVEMENT P ROJECT 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 RX PATIENTS Benzodiazepine use disorder Lack of education re: risks Attachment/preferenc e to current regimen EQUIPMENT Medical record not integrated across system Cumbersome to obtain CURES access PROCEDURES Poor coordination between care settings Poor documentation of rationale for ongoing use POLICIES No policy requiring risk assessment No policy requiring documentation for ongoing use PRESCRIBERS Policy may limit appropriate treatment Inherited patient on regimen NON-MEDICAL PROVIDERS Lack of commitment or experience with non- pharmacologic treatment Home environment not conducive for sleep Lack of education re: risks Lack of support for non- pharmacologic treatment UNSAFE SEDATIVE-HYPNOTIC PRESCRIBING ROOT CAUSE ANALYSIS

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

8. S TUDY P OPULATION 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. S TUDY I NDICATOR 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. B ASELINE D ATA FOR BHS – 2012-2013

11. B ASELINE D ATA – 2012-2013 # Performance Indicator # Patients with Prescriptions for a Sedative-Hypnotic* (Numerator) # Patients with a Billed Mental Health Service* (Denominator) Baseline Performance Indicator Goal 1 Percent of clients (age 18+) receiving a sedative-hypnotic 18261192115%20% reduction from baseline (12%) 2 Percent of older adult clients (age 60+) receiving a sedative- hypnotic 416275215%20% reduction from baseline (12%) 3 Percent of methadone maintenance clients receiving a sedative-hypnotic 18354234%30% reduction from baseline (24%) * Determined by a mean of the 8 quarters in 2012-2013

12. I MPLEMENTATION

13. I MPLEMENTATION C HALLENGES Technical Staff Client

14. T ECHNICAL C HALLENGES 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. S TAFF C HALLENGES “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. P ATIENT C HALLENGES 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. C LINIC I MPLEMENTATION

19. C LINIC S TAFF AND A DMINISTRATIVE I MPLEMENTATION 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. P ATIENT E DUCATION 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 Y EARS OF F OLLOW - UP D ATA

22. P RE - AND P OST -I MPLEMENTATION S UMMARY 1. All Medical Staff Meeting Reviewing MMT 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 Disseminate Guideline to SFGH psychiatry

23. BHS P LANS 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. Q UESTIONS ?