North York Family Health Team (FHT) has developed an insomnia reduction program for seniors aimed at reducing their use of sedative hypnotic medications. This program was led by the pharmacy and social work teams with support from the medical director and dietitian team.
The two-tier alternative treatment program includes:
- Consultation with a pharmacist: An individualized assessment and recommendations for weaning off sedative hypnotic medications, with follow-up as needed;
- A group-based cognitive behavioural therapy for insomnia (CBT-I) program: Facilitated by a social worker, pharmacist and dietitian.
In recognition of this work, North York FHT was the 2017 recipient of the Association of Family Health Teams of Ontario’s (AFHTO) Bright Lights Award for the category Clinical Innovations for Specific Populations.
Health Quality Ontario had a chance to catch up with social workers Emelyn Bartlett and Nick Maraj, and pharmacist Eric Lui to gain a better understanding of the impact the insomnia reduction program has had on patient outcomes.
Why did your FHT create the insomnia reduction program?
There were a number of factors that helped make the case for our insomnia reduction program. Evidence suggests that sedative hypnotic drugs are highly addictive and have side effects, making slips, falls and memory loss more likely. They’re also associated with longer-term side effects, such as dementia.
Anecdotally, the team of social workers in our mental health program were noticing that more senior patients were concerned about their insomnia. A review of our electronic medical records later revealed that 10% of the 20,000 seniors in our patient population have been prescribed a sedative hypnotic drug. Our team also took to heart Choosing Wisely Canada’s recommendation against the use of sedative hypnotic drugs as a first choice for treating insomnia, agitation or delirium.
With funding from Health Quality Ontario’s ARTIC Program, as well as support from management, our interdisciplinary team came together to work on developing this program.
From left to right: Eric Lui, Pharmacist, Heather Rambharack, Social Worker, Nicholas Maraj, Social Worker, Emelyn Bartlett, Social Worker, presenting a poster at the AFHTO Conference on the insomnia reduction program at the North York FHT.
Can you describe how the insomnia reduction program works?
This program is available to adults with, or at risk for, chronic insomnia who meet certain criteria. However, we decided to focus mainly on seniors. Any physician or allied health professional across our FHT sites can refer patients to one or both tiers of the program.
In the first tier, patients can consult with a pharmacist anytime throughout the year. Patients are offered information by the pharmacist on the potential risks of continuing sedative hypnotic medications in the long term. They are also offered guidance and follow-up on how to slowly taper off the sedative hypnotic medications safely.
The second tier, which is the CBT-I program, is a seven-week course that runs a few times a year. It includes:
- An orientation session;
- A session with our pharmacist about the pros and cons of medication use with individual follow up as needed;
- Sessions with our social worker to learn about CBT-I; and
- A session with our dietitian to understand how nutrition can affect sleep
There is also a cross referral process between the two tiers of the program so that patients can benefit from both. In addition, patients can also see a social worker, pharmacist or dietitian for one-on-one assistance outside of the seven-week course timeframe.
CBT-I is recommended as the initial treatment of choice for chronic insomnia by the American College of Physicians (2016 Guidelines).
In this photo: Eric Lui, Pharmacist, talking to participants in a CBT-I orientation class about sedative hypnotic sleep medications and potential ways to come off them safely
Are patients open to decreasing their sedative hypnotic medication use?
Patients’ readiness and motivation to reduce their sedative hypnotic medication use is an important factor to consider. We try to address patients’ concerns and questions in a variety of ways.
Our pharmacist uses evidence-based protocols for medication weaning, but works with each patient based on their readiness.In the CBT-I program, the group setting allows patients to hear success stories from peers who have gone through the program. We reiterate that CBT-I can be used even when using, or weaning off, sedative hypnotic medication. We provide encouragement through motivational interviewing and assess patients’ stage of change. We’re also considering meeting with patients before they begin the CBT-I program so that they can ask questions in advance.
What have been the outcomes of your program so far?
Among the 17 first-tier pilot participants:
- 93% attempted to wean or stop sedative hypnotic medication use. Of these patients, 75% successfully reduced their usage, while 20% reached absolute abstinence.
Among the 14 second-tier pilot participants:
- 79% reported an improvement in sleep quality, as measured by the Insomnia Severity Index (ISI)
- 79% reported an improvement in mood, as measured by the PHQ-9 score
- 71% reported a reduction in anxiety, as measured by the GAD-7 score
As shown in the graph below, there was a significant reduction in the mean ISI, PHQ-9, and GAD-7 scores for the CBT-I participants after they completed the program.
The team solicits qualitative feedback from participants on a regular basis. Their input has resulted in changes to the insomnia reduction program, including:
- Earlier introduction and accessibility to the pharmacist
- Integrating the dietitian’s involvement to discuss the link between nutrition and sleep
- Offering Individual follow up counselling
Patients who attended the CBT-I program reported positive feedback including:
“I was unaware of CBT-I and the tools that I have learned are making the first positive changes in my sleep issues in 20 years.”
“Sleeping much better. No more sleeping pills and waking up for much less time. It made me aware of the bad habits I got into and that I can change.”
What were your lessons learned?
- Identify your patient population’s needs: It was
important for us to ground the insomnia reduction program in our specific
patient population’s needs. We built the case for the insomnia reduction
program after reviewing the evidence around this topic, as well as our
electronic medical records, sharing staff experiences who serve this patient
population, and considering sedative hypnotic use best practices from Choosing
- Get your organization’s buy-in: Both the
interdisciplinary team and management’s buy-in was very important to move the
work forward. Our deprescribing measures have also been integrated into North
York FHT’s quality improvement plan.
- Use a team-based approach: The insomnia reduction program
was a success because patients had access to our pharmacist, dietitian and
social worker all in the same room. This approach puts client’s needs first and
contributes to the program’s success.
- Adapt as you go: It was important for us to customize
our program based on what patients were telling us. For example, we added the
services of the dietitian after hearing from patients that they wanted to learn
about the link between nutrition and sleep.
- Evaluate as you go: Monitoring various aspects of the
program was important to keep us motivated and to inform future changes and
- Have protected time to do the work: We advocated for
protected time and support from management to get the program running in a
relatively short amount of time. This was very helpful so that the team could
come together regularly and get the program up and running.
What are your next steps?
We continue to run both tiers of the insomnia reduction program and our team has been sharing our process, resources and findings with other FHTs as well. Overall, it has been a very positive learning experience for all involved. The NYFHT will continue to evaluate, improve and build upon the initial success of this timely, patient-centered program.