LESSONS LEARNED FROM A STATE-WIDE EFFORT TO REDUCE NURSING HOME POLYPHARMACY: THE INDIANA SMART CAMPAIGN

摘要

Polypharmacy is a significant quality of care and life issue in United States nursing homes. The Indiana State Department of Health (ISDH) funded a 2-year statewide quality improvement (QI) project, entitled SMART (Safer Medication Administration, Regimens, Treatments) aimed at reducing nursing home polypharmacy. Presentation objectives are to: 1. Describe the Indiana SMART campaign, and 2. Deconstruct SMART implementation through application of the Consolidated Framework for Implementation Research (CFIR). The CFIR () captures implementation complexity across five areas: Intervention characteristics; Outer setting; Inner setting; Characteristics of individuals; and Process. Data include site visit observations, semi-structured interviews with eight project champions, and written reflections from four participating physicians. SMART was designed with flexibility to allow facilities to tailor processes and goals to their organizational context, creating a challenge for project champions who desired a prescriptive approach. Champions rarely volunteered or had time allocated for the additional SMART duties. Nursing and leadership turnover were significant communication barriers. Relative to daily concerns or events, champions felt little urgency toward medication reduction, directing efforts toward more seemingly urgent problems. Facilities had processes to reduce use of psychotropic medications as required for CMS participation; over-use of other drug classes lacked regulatory ‘push’ to reduce their use. Early success in discontinuing rarely administered non-prescription medications that were ordered “as needed” let to more ambitious goal-setting. Families responded positively to project participation, and are potentially powerful change agents. Future state-wide efforts aimed at medication reduction in nursing homes can benefit from a deeper understanding of the SMART experience.