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If your hospice is typical, you have 15-30% of your patients residing in long-term care (LTC) or assisted living. In addition to the policies, procedures, rules, and regulations that govern your hospice and how care is provided, there is the added challenge of the policies, procedures, rules, and regulations under which LTCs provide care.
One of the procedural elements most LTCs follow is The AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults, commonly known as The Beers List. This is a compendium of medications that have the potential to cause an unfavorable balance of risks vs benefits and should be considered with caution or avoided altogether. First developed by Dr. Mark Beers and his colleagues in 1991 it was transferred to the AGS in 2011. In January 2019 the American Geriatrics Society (AGS) updated The Beers List.
What is The Beers List? It has 5 lists that describe particular medications with evidence they should be:
What’s new in 2019? Across its five lists, the 2019 AGS Beers Criteria® includes:
The AGS Beers Criteria® “should never solely dictate how medications are prescribed, nor should it justify restricting health coverage. This tool works best as a starting point for a discussion—one guided by personal needs and priorities as we age,” according to Michael Steinman, MD, a fellow co-chair of the AGS Beers Criteria® panel.
In support of this principle, the AGS Beers Criteria® panelists used their companion editorial (DOI: 10.111/jgs.15766) to reiterate that:
Although hospice and palliative care are specifically mentioned as exempted in the 5 lists, you will find or have found that most LTCs are fairly rigid in their application of The Beers List.
For resources and references containing more detail please see below.
In recent months we have seen an uptick in calls regarding OAB specifically related to the use of Myrbetriq (mirabegron). Myrbetriq is only available as a brand. It is a beta-3 adrenergic receptor agonist that causes relaxation of the detrusor smooth muscle during the urine storage phase, thus increasing bladder capacity. Mirabegron interacts with over 200 other drugs, 85 of which are moderate to major interactions.
The most common side effects include:
Mirabegron is dosed once daily and comes in 25mg or 50mg tablets. A 30-day supply costs approximately $500.
The antimuscarinic class of medications (oxybutynin, solifenacin, etc) are similar in clinical benefit. The cost for a one-month supply ranges from $15-$95.
Oxybutynin is also available as a transdermal patch, is over the counter, and causes fewer anticholinergic side effects. Patches are changed every 4 days. A box of 4 patches is approximately $15.
Many patients come to hospice with >8 prescription medications as well as OTCs and vitamins and supplements. The pill burden can be overwhelming and with more medications comes greater risk for drug-to-drug interactions, side effects, and adverse events.
When a patient becomes hospice eligible, it is a good time to comprehensively review their medication profile and begin the discussion about deprescribing. As clinicians, we are looking to keep medications that manage particular symptoms and consider deprescribing those medications that are of no benefit and, more importantly, those causing harm.
This is a good time to discuss discontinuing vitamins, especially the fat-soluble vitamins such as vitamin A, D, E, and K. There is some risk of vitamin toxicity associated with these vitamins. Just decreasing the number of vitamins or eliminating all together can lessen pill burden without negative effect.
Supplements present unique issues. They can increase or decrease the actions of prescription medications. Excessive doses of supplements, such as iron, can cause nausea, vomiting, and liver damage. Like vitamins, decreasing the number of or eliminating the supplements will lower toxicity risk and decrease the pill burden.
Antioxidants protect cells against free radicals which can cause damage. There are risks related to interactions with prescription medications and toxicity. For patients whose disease trajectory is at the end stage, antioxidants are more risk than benefit. Again, reducing or eliminating antioxidants will reduce the pill burden.
Although adverse effects of bisphosphates in the general public are rare, in the frail elderly the risks increase significantly. Patients who have been on a bisphosphonate >3 years will still have the benefit of the bisphosphonate for months beyond its discontinuation. Adverse effects that may be seen are severe musculoskeletal pain, esophageal cancer, ocular inflammation, ONJ, over suppression of bone turnover, and subtrochanteric femoral fractures.
Decreasing or deprescribing medications in these categories lower the risk of side effects, adverse events and decrease pill burden.
These shortages are due either to manufacturing delays or shortage of raw ingredients. This is not an inclusive list, but the listed drugs may be used for hospice patients, especially in the inpatient setting.
For a complete list of drugs on shortage follow this link:
David is a seasoned veteran of the hospice world and an essential member of the Wise Hospice Options clinical team.
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