Deprescribing is the process of medication withdrawal, intentionally stopping a drug or reducing its dose because:
It is causing side effects
It is putting the patient at risk
Is no longer of benefit
Polypharmacy is considered as taking 8 or more medications, with or without identified adverse effects. Polypharmacy has as much or more morbidity and mortality than many diseases.
In 2000 it cost $85 billion and 106,000 lives vs. Diabetes Mellitus cost $91.8 billion and 224,000 lives.
Proven benefits of deprescribing:
Reduces adverse effects
Improves quality of life
Reduces costs to the patient and the health system
Key occasions to deprescribe:
Emergency Room Visit
To improve medication adherence measures, at the beginning of the year, before the measure is activated by the second dispatch, review and deprescribe what the patient should not take.
The process of medication reconciliation is an opportune occasion to deprescribe. To complete this process, your office staff may instruct the patient to bring all medications they use (prescription, OTC, natural supplements, etc.).
When medication reconciliation, it is important to take into consideration the following characteristics of the patient:
Age (Evaluate elderly using medications from the Beers List)
Is there an active diagnosis for this medication?
Is this medicine used to treat side effects of another medication?
Is it the correct dose?
Could abnormal lab results be drug effect?
Is the medicine really helping you or is there no longer any benefit in treating your condition?
Are there adherence barriers due to the cost or plan coverage?
Could the falls you have be caused by the medication?
Is insomnia a side effect of the medication?
Is drowsiness caused by the medication?
Is anorexia caused by the medication?
Is weight gain or loss the effect of the drug?
Does the patient have good adherence to therapy?
If your doctor says it’s possible, would you agree to stop one or more of your medications?
I want both of us to work together to reduce your medications.
In this project to reduce your medicines I will not stop prescribing what you need
Which of your medicines do you really need?
Which drug do you want us to focus on first?
In terms of health what would make you feel better and more independent?
That medicine can take many years or decades to give you benefits, better focus on the medicines that can benefit you now, the ones that make you feel better and maintain your function and independence.
Let’s avoid medicines that can cause side effects.
Let’s avoid medicines that increase the risk of falls.
Remember to complete the following steps when deprescribing:
Educate the patient about the medications they should discontinue and the method of safely disposing of medications at home.
Update the list of medicines in the patient’s record.
Write on the prescription the medication to be discontinued to offer instruction to the pharmacy and avoid dispensing refills of medications that the patient should not continue taking.
By Dr. José R. Muñiz Meléndez, MD, Geriatrician Castellana (E) Medical Director
By: Danay Pérez Pérez Health Services-Health Education
According to the American Diabetes Association (2022) diabetes patients are greatly influenced by healthcare providers who impact their lives. As health ambassadors, we recommend the following tips to promote the best care for our patients:
Ensure that your treatment decisions are accepted and understood by patients.
Consider creating or referring community support groups for diabetes management as needed.
Lead care efforts with a holistic, patient-centered approach, according to individual needs.
Share tools or educational material that allow patients and/or family members to know how to avoid complications of diabetes.
Examine whether the patient is complying with their medical treatment according to recommendations offered.
Implement “active listening” strategies to find possible doubts or needs that have not yet been addressed by the provider.
Although the circumstances of each human being can be diverse, health providers like you are key for our patients to achieve a full quality of life. American Diabetes Association (2022) Standards of Medical Care in Diabetes—2022. Retrieved October 17, 2022. https://doi.org/10.2337/dc22-Sppc
It is known that chronic diseases such as diabetes, chronic cardiopulmonary and kidney diseases constitute a burden on the health system in the United States as much as ours. More than 60% of the U.S. population suffers from one or more chronic conditions, which constitutes more than 80 to 85% of health expenditure. This has become more evident in the pandemic as more than 90% of deaths caused by COVID-19 suffered from one or more chronic conditions. To this we add the limitation of access to the health service, where statistics show that screening tests for diabetes and cholesterol evaluation reduced by more than 80%, as did first-line prescriptions causing a reduction in adherence and control of these conditions. Other factors that contribute to the increase in these chronic conditions are sedentary living, poor nutrition, socioeconomic status, and coexisting comorbidities.
Technology and its changing trends became one of the best allies in the face of this global crisis. This paper presents the basic concepts, evolution and usefulness that technology such as artificial intelligence can have. In general, artificial intelligence is not a new concept since its beginnings are based on the 50s of the last century. This has evolved in its characteristics and definitions. For example: artificial intelligence sought to imitate certain activities that humans perform through machines and / or computer programs, its most basic form were programs of board games such as chess, among others between the 1950s and the late 70s.
From the 80s, machines had the ability, through data collection and integration, to interpret and perform certain tasks without the need for explicit programming. This was known as: machine learning. Already from 2010 the term “Deep Learning” is used in reference to a data entry that is carried out through a red similar to the human central system and that is able to adapt.
Examples of these are information use systems such as Siri, Alexa, facial recognition, drones, motor vehicles, filters in programming (spams filters). But even more so in medicine where today there is robotic surgery like da Vinci, the documentation of medical information, interpretation of images and histopathological cuts. Growth is estimated for 2026 in applications such as robotic surgery, virtual healthcare, administrative work, fraud detection, error production, medication management, and preventive diagnostics. These factors will change fundamental aspects of health services.
Another segment that has shown evident growth is the monitoring of health parameters with portable machines, such as glucose, oxygen saturation, blood pressure and heart rate meters, among other metrics. This, with the portability of a cell phone, a watch or other clothing piece, which is essential for the prevention of chronic conditions.
These tools will also facilitate connectivity between health providers for interconsultations, monitoring of emergency room visits and admissions, in order to coordinate follow-ups in post-acute care quickly and efficiently.
But this path of change to technology also has its challenges, since we must take into account the high cost of technology, regulations and their implementation so that they favorably impact a reduction in incidence and prevalence in these chronic diseases. Proper analysis and decisions will help improve the patient’s quality of life and reduce mortality from these conditions.
Medication adherence is defined as administering medications in the amount and time in which they were prescribed by the primary care physician or specialist. Similarly, it is described as the commitment that a patient has to administer their medications as prescribed. Annually, about 51% of patients with chronic conditions, such as diabetes, hypertension and kidney problems, suffer complications, sometimes fatal, as a result of not taking their medications as prescribed. These complications are mostly associated with aspects of adherence and in other instances, safety aspects in therapy.
Good medication adherence is associated with significant decreases in morbidity, mortality, and hospitalizations. However, despite the clear benefits of adherence, patients often have difficulty taking their medications as prescribed. Among the factors that have been linked to a decrease in adherence are:
Fear of developing adverse effects or experiencing unwanted effects
Complexity in the therapeutic regimen (polypharmacy or multiple administrations throughout the day)
Lack of knowledge about the indication of the medicine
Poor accessibility to prescribed treatment
Polypharmacy (using eight or more medicines)
Depression and social aspects, among others
There are many ways we can help our patients identify their treatment barriers and overcome them to improve their adherence. These strategies include:
–Educate the patient about their medication regimen: On many occasions, patients do not take their medications because they do not understand the need for the medication, the nature of the side effects, or the time it will take to see results. That is why, when prescribing a medication, it is important to educate you about it and provide them with the necessary tools to empower you with your treatment.
– Drug accessibility: Validate your patient’s drug coverage so that you can choose the alternatives available on your formulary and likewise, you can know in advance if the patient will need additional information in the medical prescription, so that the drug is approved. The high cost can lead to patients not bringing their medications or even rationing the doses of therapy in order to extend the days of supply. Consider the latter, especially for patients who reach the top of their health plan coverage throughout the year.
– Simplify the therapy regimen: try in each meeting, review the indications of the medications that your patient takes, he may be taking medications that are not indicated, which complicates the therapeutic regimen. Similarly, simplify the number of tablets by consolidating the treatment into one tablet formulations containing more than one active ingredient.
–Involve family or friends: Creating the habit of taking medication can take weeks, according to studies conducted in the outpatient setting. Involving family or friends in this process can help the patient in developing a greater commitment to their therapy.
Without a doubt, the health and well-being of our patients is a priority. That is why you can recommend the following tips to your patients:
– Use a pillbox that you can fill weekly.
– Recommend taking the medicines at the same time every day, this way the patient will create the habit and forget it less.
– Advise using alarms and reminder notes in places that the patient frequent during the day.
– Recommend NOT skipping any doses and emphasize the importance of not stopping taking medications on his own.
– Discuss with your patient the importance of informing the natural products or supplements you want to start. This will make it possible to validate the safety of these based on the patient’s existing conditions and other clinical parameters (e.g. renal function) or medications (drug-drug interactions).
– Finally, ask the pharmacist or pharmacy of the patient’s choice to assist you in the development of a table of medications with the hours of administration and requirements of each of them (e.g. take with food, take it on an empty stomach, among others).
Remember that better adherence to prescribed treatment will be an additional step for your patient towards a better quality of life.
Author: Dr. Cathyria M. Marrero Serra, PharmD, BCPS
In Castellana Physicians Services we have designed a model of multispecialty clinics, to support the primary care physician and medical groups on the island. Offering access to health services to meet the needs of patients and the population with chronic conditions.
In our Castellana Multisalud clinics we have the services of specialists, nurses, and other support staff such as health educators, nutritionists, social workers and doctors in pharmacy.
In order to provide greater coverage, MMM members will now be able to access the Multisalud Castellana Clinics located in Caguas, Carolina and Aibonito, where they will be provided with individualized and centralized care in coordination with the patient’s primary physician. The specialists they need in one place.
We recently opened a new Castellana MultiSalud clinic in Aibonito for our mountain area patients to facilitate access and promote social welfare. The clinic also has a conference room, social club, children’s area and free parking.
In the care centers, the patient will be able to access specialized services such as pneumology, neurology, psychology, endocrinology, psychiatry, nephrology, dermatology, cardiology, among others.
The hours of operation in our clinic are Monday through Friday from 7:30 a.m. to 4:30 p.m.
Services and specialists vary by clinic.
Carolina 787-665-0174 Carolina Shopping Court Suite 205
Caguas 787-961-0760 Plaza Bairoa Bairoa Industrial Park, carr. # 1
Aibonito 787-545-7073 Bo. Llanos Carr. PR 725 Km 0.5 PRIDCO Industrial Park
With all the medical services in one place, the new Castellana Multisalud clinic was inaugurated, which will provide service exclusively to MMM and MMM Multihealth affiliates in Aibonito, and the neighboring towns. The new health center was developed at a cost of $10 million, providing easy access to a greater number of services not available in the mountain area.
“Before opening the clinic, 93% of patients had to go outside the region to receive services from specialist doctors, that is a thing of the past. Now residents have the best health care services available. That is why Castellana Multisalud came to the mountains, to serve the members with an excellent team of health professionals, within unique facilities that are characterized by their spaciousness, modernity, comfort, and high technology, “explained Dr. Raúl Montalvo, president of MSO and Castellana Physicians Services.
The clinic offers access to the services of medical specialists that were mostly not easily available in the center of the island, such as endocrinologists, neurologists, clinical social workers, nutritionists, psychologists, dermatologists, cardiologists, gastroenterologists, and pneumologists. Having all these specialists under one roof reduces the patient’s waiting time for services, and allows for an integrated model with health services and centralized clinical information in support of the primary care physician and mountain medical groups.
“Another aspect that makes the clinic unique is the prompt opening of a modern emergency room with 10 stretchers and two minor procedure centers, which will represent a great convenience and will allow care situations to be addressed quickly. Highlighted in this revolutionary concept of health are spaces such as the social club and children’s area, which contribute to community interaction,” said Waldemar Ríos, MSO’s chief medical officer.
In the coming months, the services of vaccination, pharmacy, X-ray radiology, bone densitometry, CT Scan, mammography and sonography will be added to the clinic. The clinic is located in Barrio Llanos highway 725 KM 0.5, PRIDCO Industrial Park and its schedule is From Monday to Friday from 7:30 a.m. to 4:30 p.m. Primary medicine services will soon be available in extended hours Monday through Friday, until 8:00 p.m.
For more information you can call 787-523-2458 or visit social networks on Facebook and LinkedIn.
About Castellana Physicians Services
Castellana Physicians Services, LLC (Castellana), part of the MMM Holdings, LLC group in Puerto Rico, provides state-of-the-art support services to medical groups, primary practitioners, and subspecialists, among others. Castellana has been an association of independent providers (IPA), which has been dedicated exclusively to providing services to physicians serving the elderly and disabled population of Puerto Rico. Currently, Castellana consists of four independent IPAs, with over 500 primary care physicians (PCPs). Castellana is a leading company in the Mediare Advantage industry. Its operations are recognized for being pioneers in implementing a coordinated comprehensive health model based on high quality standards, achieving outstanding results. Castellana’s Mission is to optimize medical practice to promote highly cost-effective and excellent services to the patient. Y0049_2022 4002 0112 2_C
Medical Director of Castellana (North Metro Region)
The GA assesses the medical, social and environmental factors that affect the welfare of the population over 65 years of age. It helps us to identify functional status, risks of falls, medication review, nutrition, vision, hearing, cognitive problems, mood disorders and alterations in daily living functions.
Reviewing statistical data, in 2015 the population over 65 years old represented 31% of the population in the United States. Since 2013 every day there are 10,000 baby boomers turning 65 and entering Medicare.
The GA has been used in hospitals, home care and clinics, demonstrating that it helps in the documentation and detection of situations in the geriatric population. The population with the greatest opportunity are patients with multiple morbidities, cognitive changes, changes in their functional status,
adherents to your medications, in the process of transition of care, unexplained weight loss and / or other situations that are of concern to your family member. It is not very useful in terminal patients, with advanced dementia or with total functional dependence.
The GA complies with the elements that Medicare recommends about the content of the visit.
Next, the fundamental components to be reviewed in this population. Many of these data can be collected through the patient or family members.
Identify all the doctors you visit (specialists) and if you receive any type of service (therapies, etc.).
Estimation of risk factors:
Consider health (good, regular, poor)
Behavior (alcohol, drugs, smokes, sexual activity)
Functional capacity (daily living activities)
Review of recent medical history and use of medications.
Reconciliation of medications including OTC (check
List of Beers – high-risk medications STOP I START
Risk of depression (PHQ2 – PHQP or 15 scale of geriatric depression)
Functionality and Security / simple questions: Do you need help getting dressed, bathing, walking or eating? Have you experienced changes in this year? Do you have hearing problems?
Cernimiento for urinary incontinence
Screening for malnutrition or weight loss: Have you lost weight in the past months? Minimum nutritional estimate
This visit can be coded G0438 (initial visit), G0439 (subsequent visit)
Immunization status (influenza vaccine, pneumonia, TD, Herpes Zoster)
After we have the GA we proceed with an action plan to be carried out in order of priority of the findings.
If you want more information, we can give you a copy of the article of the AAFP magazine, June 15, 2018 edition.
The blood pressure control measure (CBP) aims to keep the patient hypertensive at a control of * 129/79 or less. To comply with the Medicare Ratings and HEDIS Rating Program metrics, you must bill the F code corresponding to systolic and diastolic blood pressure. Also, include the first category procedure code, which corresponds from 99211 to 99215.
Remember to monitor blood pressure at each visit (including 99211) and document it in the patient’s medical record. The value used for compliance with this measure will be the last meeting of the year.
Parameters of CBP according to the new Guidelines of the American College of Cardiology and the American Heart Association.
Supplies of strips and lancets do not require pre-authorization as long as they are requested by Medicare, as shown below.
If the patient requires a greater quantity of supplies, it is considered a surplus, in these cases it will be necessary to submit an order to the plan with medical justification. Surplus service requires pre-authorization. If the supply is requested as established by Medicare, it can be submitted directly to the Service Provider.
Help us to inform your work team and patients. Good communication helps achieve effectiveness in processing requested orders.