Transcript Improving Medication Management for Care Management Clients

Improving Medication
Management for Care
Management Clients
June Simmons
CEO
Sandy Atkins
Associate Director
Partners in Care Foundation
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Los Angeles, CA
Changing the shape of health care
Collaboration * Innovation * Impact
Design, develop and pilot new programs that
will serve as replicable models of care
Session Objectives
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Describe the Medication Management
Improvement System and how it can improve
medication management among consumers.
Identify successes and challenges when
implementing a new intervention into existing
care management
Discuss trends in polypharmacy and the
importance of implementing evidence-based
health promotion programs for older adults.
Medication Management
Project Rationale
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Patient Safety - Medication errors are:
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Serious: At least 1.5 million preventable adverse drug events
(ADEs) each year; 7,000 deaths per year due to ADEs. 1,3
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Frequent: Up to 48% of community dwelling older adults have
medication-related problems 2
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Costly: Drug-related morbidity and mortality for seniors exceeds
$170 billion (includes hospital and long-term care admissions) 2
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Preventable: At least 25% of adverse drug events in ambulatory
settings are preventable.
Olmstead Act: Equity issue - Pharmacist review mandatory for all
SNF and medication review for ICF, ADHC
1. IOM (1999) To err is human: Building a safer health system. Kohn, L., Corrigan, J., Donaldson, M. (Eds.)
National Academy Press, Washington D.C.
2. Zhan C, Sangl J, Bierman AS et al. Potentially inappropriate medication use in the community-dwelling
elderly: findings from the 1996 Medical Expenditure Panel Survey. JAMA. 2001; 286:2823-9.
3. IOM (2006) Preventing Medication Errors.
Evolution of Medication Management
Program
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Hartford Phase 1993-2003 HOME HEALTH AGENCY
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Vanderbilt Univ. randomized controlled trial to improve
medication use; developed, tested, disseminated and adopted
AOA Evidence-Based Prevention Initiative, 2003-2007
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Community-Based Medication Intervention
 Model successful in Medicaid waiver programs
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Next Phase, 2006–2010, Hartford Foundation
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Taking meds management statewide first then nationwide in care
management!
Evidence-Based Origins
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Hartford/Vanderbilt Randomized Controlled Trial in
Medicare home health patients aged 65+.
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Developed by Visiting Nurse Assoc-LA (now Partners), Visiting
Nurse Services, NYC & Vanderbilt University researchers
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Randomized, controlled trial proved the efficacy of the
Medication Management Model in home health agencies
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The model used a pharmacist-centered intervention to identify &
resolve medication errors
19% had potential medication errors using expert panel’s
criteria
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Medication use improved in 50% of intervention patients,
compared to 38% of controls (p=.05) when a pharmacist helped
homecare staff
Core Elements
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Screening to identify potential errors and
medication-related problems;
Assessment of the client’s condition and
adherence based on established guidelines;
Consultation between staff and pharmacist to
develop a plan of action based on protocols;
and
Follow-up with physician and client to improve
medication use.
Medication Risk Assessment
Screening
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RN care managers collect clients’ medications lists and
clinical indicators
 Vital signs, falls, dizziness, uncharacteristic confusion
Med lists are screened by a consultant pharmacist.
Focus on the four most common medication errors:
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Unnecessary therapeutic duplication;
Cardiovascular medication problems related to dizziness,
continued high blood pressure, low blood pressure, or low
pulse;
Falls, dizziness, or confusion possibly caused by
inappropriate psychotropic drugs;
Inappropriate use of non-steroidal anti-inflammatory drugs
(NSAIDs) in those with risk factors for peptic ulcer.
Evidence of Effectiveness
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615 clients in 3 Medicaid waiver sites were screened
49% (N=299) had potential medication problems.
Record review and consultation with the client led the
pharmacist to recommend:
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Continue the medications - necessary for pain/symptom control;
 Collect more information - vital signs and other clinical indicators
 Verify dose and frequency with which the client was taking the
medication and revise the medication list accordingly; or
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Change medications or dosage.
29% of the 615 clients had confirmed medication problem pharmacist recommended a change in medications, including
re-evaluation by the physician.
61% (N=118) of recommended changes were implemented.
Medication Management
Project Purpose
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Partners in Care is conducting a multi-phase study to
apply evidence-based medication management to
Medicaid waiver care management programs in
California and nationwide.
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Identify the prevalence of potential medication problems
in high-risk older adults receiving Medicaid waiver caremanagement services at home.
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Improve client health and safety by managing
medications
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Evaluate client and program-level outcomes.
Why Care Managers?
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Focused on maintaining health status, delaying
institutionalization, and improving linkages with medical &
community resources
Already collecting medication and clinical information
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Visit frail, low-income seniors in their homes
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Established rapport with and care about their clients
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Linguistically and culturally competent staff
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Knowledgeable of available resources
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Intervention – From Alerts to Action
Medications entered
into computerized
risk assessment
screening system
Pharmacist
recommends
changes to
medications
FOLLOW
THROUGH
ALERT
Pharmacist reviews
medications and
client condition to
confirm problems
warranting reevaluation by the
physician
Physician informed
of problems and
pharmacist
recommendations
Software
Produces Alerts
regarding potential
medication problems
CONFIRM
VERIFY
Care Manager reviews
medication alerts with
client to verify dose
and frequency
THEN updates
medication list if
needed
Care
Manager
follows up
with client
Care Manager
documents all actions
and consultations in
client record system
Indicators of Agency Readiness
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There must be a “felt need”
 A sense of the importance and urgency of the problem
There must be a champion
 Pull others along, learn systems, mentor others, serve
as an example, and cheerlead when there are
successes.
There must be underlying stability
 Resources viewed as adequate
 Staff turnover minimal
 Recovery time since last big change
Implementation Experience
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Start small
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Champion & small team
 New enrollees only
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Pharmacy students under
professor supervision
 Local community pharmacists
that serve care management
clients.
 Part D Medication Therapy
Management
Changing care management
practice
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Ongoing training
Staff mentor each other
Staff choice in design options
Leadership emphasizes the
importance of follow-through;
Clear policies and protocols
Rewards, challenges,
contests
Help with routine data entry
Use community pharmacy
resources creatively
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Best ways to communicate
with physicians
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Usually FAX
 Pharmacist, nurse, or care
manager
Sustaining the Program
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Provide ongoing support and education for staff
Train new staff members in orientation
Arrange for pharmacist consultant
Identify best practices and problems.
Provide feedback to staff, funders, and community
partners
Identify and recognize program champions
Provide updates and an opportunity to share ideas and
problem-solve
What does it take to succeed?
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Staff open to enhancing scope of practice for
client health and safety
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A culture that values continuous quality
improvement and evidence-based practice
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Staff using computerized client assessment
system
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$100/month for online medication screening
tool
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Able to arrange for an average of 15 minutes of
pharmacist time per client screened.
What are the benefits?
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Improved client safety and quality of life
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Use of a modestly priced, secure on-line medication
management tool
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Personalized consultation to adapt the intervention
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Site support resources to help defray initial costs
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Training on medication use and problems among older
adults
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National prominence as part of the vanguard in bringing
this AoA evidence-based disease prevention program
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National benchmark comparisons
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Regulators view as indicator of high quality
Who can participate?
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At this time there are two absolute prerequisites to
participate as demonstration project site:
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Must be a Medicaid waiver program for elders
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Care managers must be using a computerized client
assessment system
Sites must also:
 Collect
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medication and clinical information
Arrange for a pharmacist or medication consultant
Next Steps
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For more information: www.HomeMeds.org
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Readiness self-assessment tool (collaboration with
NCOA) available on-line in October
Identify a consulting pharmacist who can
screen medications and help care managers
with follow through
Contact the Medication Management
Improvement System team:
 Mira
Trufasiu, Project Manager - 818.837.3775 x112,
[email protected]
 Sandy Atkins, Project Director - 818.837.3775 x111,
[email protected]