HFHT HEALTH PLANNING TOOL

Step 1 - Discovery

  1. What issue(s) / problem(s) do you want to solve / improve?
  2. Improve the management of chronic insomnia using Cognitive Behavioural Therapy – Insomnia (CBT-I)
  3. Optimize the resources we have at the HFHT to provide CBT-I services
  4. Minimize long-term use of pharmacotherapy, such as benzodiazepines or Z-drug (e.g., zopiclone, zolpedem) for the treatment of chronic insomnia as the harms of these drugs (e.g., falls, dizziness, dementia, fractures) may outweigh the benefits (e.g., sleep), particularly in the elderly patients.
  5. Improve appropriate prescribing for the management of chronic insomnia (e.g., deprescribing of benzodiazepine in the elderly)
  6. How does this initiative align with the Strategic Plan and or Core Directions?
  7. Strategic Plan
  8. Develop high functioning, evidence-based teams
  9. Pharmacists to be trained into providing evidence-based information on chronic insomnia to prescribers
  10. Improve access to evidence-based team care to all HFHT patients in practices
  11. Offering CBT-I to the patients in a timely manner through individual mental health counselors, shared medical appointments, pharmacist consultations, group visits at the HFHT if available
  12. HFHT’s Core Directions
  13. HFHT Service Delivery Model
  14. Appropriate prescribing
  15. Decrease benzodiazepine and Z-drug use in the elderly
  16. Access to Services – CBT-I in a timely manner
  17. Advocate for health and wellness
  18. What already exists, (community, HFHT)?
  19. Mental health counselors offer CBT-I, but not all clinician are aware of this and may not refer patients for just CBT-I
  20. OPEN (Ontario Pharmacist Research Collaboration) project, deprescribing project in Ottawa (Bruyere Research Institute)
  21. Toward Optimize Practice – Management of Adult insomnia (Alberta)
  22. Websites on CBT-I
  23. Patient resources on insomnia (website, Choosing Wisely Canada, etc)
  24. Has this been tried before, if so;
  25. What have we learned?
  26. CBT-I group sessions a few years ago at the HFHT office was not well received, poor uptake
  27. Not very many clinicians were aware of this group session
  28. How are we currently performing?
  29. At the practice level:
  30. Some individual CBT-I counseling from mental health counselors
  31. Some pharmacists involved in benzodiazepine or Z-drug deprescribing
  32. Is there evidence/research supporting your idea?
  33. Dr. Judith Davidson were able to provide CBT-I to patients of the Kingston Family Health Team and reduce drug use
  34. Evidence-based clinical practice guideline for deprescribing benzodiazepine receptor agonists are to be published soon
  35. Benzodiazepine and inappropriate prescribing recently published
  36. What is your proposed solution?
  37. Pharmacists to provide an academic detailing service (individual or small group education) to clinicians on the management of insomnia, promoting CBT-I and minimize pharmacotherapy when possible.
  38. CBT-I to be offered through various ways:
  39. Individual counseling by mental health counselors
  40. Shared Medical Appointments – group settings within a primary care office (e.g., pilot sites such as King West Medical)
  41. Group visits on CBT-I to be held at 123 James Street

Discussion of Issues and Concerns:

  • Patients may not want to stop their sleeping pills because it works
  • More work for clinicians to deprescribe (more frequent monitoring (every 2-4 weeks))
  • What about the physicians who do not have a pharmacist? Will they get academic detailing?

Step 2 - Project Proposal

  1. Who will be Involved in the project?
  2. Pharmacists will provide the education to the clinicians, mental health counselor, nurses
  3. Shared Medical Appointments in some pilot offices (physician, mental health counselor, and pharmacist) for 5 weeks involving CBT-I and/or deprescribing of medications – may or may not involve the facilitator for that practice
  4. CBT-I Group sessions at the HFHT (Tricia Brinn, Catherine MacPherson-Doe to help organize)
  5. Defining Success – what are your goals/targets?
  6. To review the evidence and management of adult insomnia with clinicians, mental health counselors and other allied health of the Hamilton Family Health Team for those who have a pharmacist within their practice (target = 80%)
  7. For patients to have ready access to CBT-I (target = 50%)
  8. Reduce the number of benzodiazepine and Z-drug use for treatment of insomnia only (target = 20%)
  9. Milestones (key steps and/or deliverables)
  10. Pharmacists to deliver the academic detailing material on chronic insomnia management
  11. Develop and pilot a few models of Share Medical Appointments for CBT-I (involving the pharmacists, mental health counselor, physician)
  12. Physicians or team to refer more patients to mental health counselors for CBT-I
  13. Use the EMR to identify those patients on benzodiazepines or Z-drugs for insomnia and work with health care team to develop a care plan for them (e.g., CBT-I, deprescribing or tapering schedule, etc)
  14. What resources do you need?
  15. Mental Health Counselors
  16. Pharmacists
  17. IT – to help develop and incorporate the sleep disorder questionnaire, sleep diary, insomnia severity index, patient handouts, etc into the EMRs
  18. CBT-I workshop – opportunity for pharmacists and other health care professionals to attend a 1-2 day workshop through either McMaster University or Hincks-Dellcrest Centre ($2500+mileage+lunch)
  19. What are you timelines?
  20. July/August – have an draft of the CBT-I 5-week session ready
  21. September/October – train pharmacists on the evidence – including training on CBT-I
  22. September/October – train mental health counselors on the CBT-I 5-week group session?
  23. September/October – have pilot sites ready to start Shared Medical Appointments
  24. September/October – all forms on Insomnia (validated assessment forms, sleep diary, patient handouts be readily available for the EMRs
  25. October – pharmacists to detail the clinicians on the evidence-based materials
  26. September/October/November (pending availability?) – guest speakers – Dr. Gottschalk? On treating and managing insomnia?
  27. When and what will be reported?
  28. Evaluation forms on the chronic insomnia topic will be given to the clinicians to be filled out to evaluate the key messages, the academic detailer (aggregrate data in 6 months after program started)
  29. Evaluation forms for the patient to fill out after the group session (after each group session)

Step 3: Monitoring Dashboard

  1. Status of project cycle (Plan-Do-Study-Act)
  2. Data/Process (Indicators and targets)
  3. Issues and Risks
  4. Action Plans and Recommendations

Step 4: Evaluation

  1. Stakeholders (comments from people or population targeted)
  2. Recommended Next Steps