Transcript Detecting & Improving Medication Problems

Detecting & Improving Medication
Use Among Vulnerable Elders:
A Community-Based Medication
Management Intervention
Gretchen Alkema
VA Greater Los Angeles Healthcare System
Kathleen Wilber
USC Andrus Gerontology Center
June Simmons, Sandy Atkins, Mira Trufasiu, & Dennee Frey
Partners in Care Foundation
Gerontological Society of America Meeting
November 19, 2007
Acknowledgements
Collaborators
Funding Support
USC Andrus Gerontology Center
Administration on Aging
Evidence-Based Prevention
Initiative (#90AM2778)
Kathleen Wilber, PhD
Partners in Care Foundation
Dennee Frey, PharmD
June Simmons, CEO/LCSW
Mira Trufasiu, MSG
Sandy Atkins, MPA
Susan Enguidanos, PhD
Huntington Hospital Senior Care
Network
Eileen Koons, LCSW
Lois Zagha, MFT
John A. Hartford Foundation
Doctoral Fellows Program in
Geriatric Social Work
AARP Scholars Program
VA Postdoctoral Fellowship
(#TPP 65-007)
Problem of Medication Errors

65+ = 12% of population but consume ⅓ of all drugs

19 - 48% elders in community w/ med-related problems

7,000 deaths annually by adverse drug events

Associated hospital costs = $2 billion

¼ of adverse drug events are preventable
Evidence-Based Practice (EBP)
in a New Setting
Implemented tested medication management
protocols from:

Medicare home healthcare RCT
to…

Medi-Cal waiver care management
Home Healthcare Context

Site: Medicare-certified home healthcare

Population: 65+ w/ skilled nursing need & MD orders

Staff: Nurses w/ pharmacist support

Length of Stay: Up to 6 weeks

Contact: Up to daily visits
Care Management Context

Site: Medi-Cal waiver care management

Population: 65+ dual eligibles w/ functional impairment

Staff: Nurses & social workers w/ pharmacist support

Length of stay: 1 month to 3+ years

Contact: Phoned monthly & quarterly home visit
Care Management Sample (N=615)
Site #1: n=216
Site #3: n=126
Site #2: n=273
Targeted Medication Problems
(Brown et al., 1998, Meredith et al., 2001)
1.
Unnecessary therapeutic duplication
2.
Psychotropic drug use w/ confusion or falls
3.
Cardiovascular medication problems
4.
Use of non-steroidal anti-inflammatory drugs
(NSAIDs) with peptic ulcer risk
Research Design
Prevalence
1. Screen for
medication problems
using the
Home Health Criteria
2. Pharmacist
confirms problem
Time 1
Time 2
6. CM follow up to identify
changes
3. If Yes, Pharmacist &
CM develop care plan
4. Contact prescribing
MD
5. CM discusses
problem & solution
with participant and/or
caregiver
3 Months
·
Was medication
problem resolved?
·
If yes, what was
changed?
·
If no, why not & follow
up plan?
Research Design
Prevalence
1. Screen for
medication problems
using the
Home Health Criteria
2. Pharmacist
confirms problem
Time 1
Time 2
6. CM follow up to identify
changes
3. If Yes, Pharmacist &
CM develop care plan
4. Contact prescribing
MD
5. CM discusses
problem & solution
with participant and/or
caregiver
3 Months
·
Was medication
problem resolved?
·
If yes, what was
changed?
·
If no, why not & follow
up plan?
Research Design
Prevalence
1. Screen for
medication problems
using the
Home Health Criteria
2. Pharmacist
confirms problem
Time 1
Time 2
6. CM follow up to identify
changes
3. If Yes, Pharmacist &
CM develop care plan
4. Contact prescribing
MD
5. CM discusses
problem & solution
with participant and/or
caregiver
3 Months
·
Was medication
problem resolved?
·
If yes, what was
changed?
·
If no, why not & follow
up plan?
Care Management Sample
(N=615)

81 years old

80% female

53% widows

40% lived alone
Photo by Rollin Riggs, NY Times

36% new to care management
Race/Ethnicity by Site (N=615)
80.0%
60.0%
Site #1
Site #2
40.0%
Site #3
20.0%
0.0%
Caucasian
AfricanAmerican
Latino/a
Asian/PI
Other
Language Preference
(N=615)
Spanish
22%
Armenian
6%
English
59%
Chinese
2%
Other
11%
Health Status (N=615)

Mean # of meds = 8.76 (SD=4.3); 12+ meds = 22%

38% ED, Hospital, or SNF in previous year

22% falls in previous 3 months

27% dizziness

31% confusion
Screened 3 MSSP Sites
using Home Health Criteria:
615 Participants
Screened 3 MSSP Sites
using Home Health Criteria:
615 Participants
No Potential Problems:
316 Participants (51%)
Potential Medication
Problems:
299 Participants (49%)
Screened 3 MSSP Sites
using Home Health Criteria:
615 Participants
No Potential Problems:
316 Participants (51%)
Potential Medication
Problems:
299 Participants (49%)
Pharmacist Review
Problem Not Confirmed: 118 Participants
· False Positive: 83
· Unconfirmed: 25
· Terminated from MSSP: 10
Confirmed Medication
Problems:
181 Participants (29%)
Screened 3 MSSP Sites
using Home Health Criteria:
615 Participants
No Potential Problems:
316 Participants (51%)
Potential Medication
Problems:
299 Participants (49%)
Pharmacist Review
Problem Not Confirmed: 118 Participants
· False Positive: 83
· Unconfirmed: 25
· Terminated from MSSP: 10
Confirmed Medication
Problems:
181 Participants (29%)
Terminated from MSSP:
19 Participants
Intervention Group:
162 Participants (26.3%)
Screened 3 MSSP Sites
using Home Health Criteria:
615 Participants
No Potential Problems:
316 Participants (51%)
Potential Medication
Problems:
299 Participants (49%)
Pharmacist Review
Problem Not Confirmed: 118 Participants
· False Positive: 83
· Unconfirmed: 25
· Terminated from MSSP: 10
Confirmed Medication
Problems:
181 Participants (29%)
Terminated from MSSP:
19 Participants
Intervention Group:
162 Participants (26.3%)
3-Month Follow Up for
Medication Improvement:
99 Participants
(61% of Intervention Group)
Attrition
10 left before med problems confirmed



19 left before intervention completed



↑ fallers (p<.05)
100% w/ 1+ potential problem (p<.001)
↓ # of meds (p<.05)
Main reasons: LTC, died, or moved
Prevalence Results (N=615)
Potential
Medication Problem
N
%
Confirmed
N
%
Any
299
48.6%
181
29.4%
Ther. Duplication
149
24.2%
87
14.1%
Psychotropic
88
14.3%
65
10.6%
Cardiovascular
87
14.1%
27
4.4%
NSAIDs
79
12.8%
53
8.6%
Associated Characteristics

Any problems ~ ↑ age, new enrollment, & ↑ meds

2+ problems ~ ↑ meds

Therapeutic duplication ~ ↑ meds

Psychotropic ~ living w/ someone, new enrollment,
ED/hospital/SNF, & ↑ meds

Cardiovascular ~ new enrollment
Problems by # Meds
% of Sample
50%
40%
All
Problems***
30%
2+
Problems***
20%
Therapeutic
Duplication***
10%
Psychotropic
w/ Falls*
0%
1-3
4-6
7-9
# of Medications
10-11
12+
Intervention Results (N=162)
Screening to
Intervention
Medication Change
at 3 Months
(N=615)
(N=162)
%
N
%∆
162
26.3%
99
61.1%
Ther. Duplication
79
12.8%
49
62.0%
Psychotropic
59
9.6%
23
67.6%
Cardiovascular
24
3.9%
11
45.8%
NSAIDs
44
7.2%
22
50.0%
Medication Problem
Any
N
Staff Comments

“As a SW, I became aware of potential dangers
or complications of some medications; I now look
at all medications my clients are taking”

“No or slow response from the doctor…some
clients have taken certain medications for so long
that they were unwilling / fear to change”

“Uncomfortable addressing this issue with MDs ~
feel it is beyond my scope of practice”
Conclusions

Med problems highly prevalent in Medi-Cal
waiver sample

Intervention successful in care management

Critical need for meds management across
continuum of care

Payment sources for meds management
Next Steps

Disseminate Medication Management Improvement
System ~ funded by Hartford Foundation

Computerized screening for potential problems


Integration into MSSPCare (by RTZ Associates)
Stand alone online version & algorithm for other software

Statewide replication in MSSPCare sites

National replication -- 2+ states


NCOA Readiness Tool
Seeking potential sites for 2008
Photo by JL Forter