Transcript Vital Aging Research and Demonstration Center

Strengthening Care
Management by
Reducing Medication
Problems
June Simmons
CEO
Mira Trufasiu
Project Manager
Gretchen Alkema
Evaluator
Sandy Atkins
Project Director
Authors:
J. Simmons, S. Atkins
M. Trufasiu, G. Alkema,
K. Wilber, D. Frey
Partners in Care Foundation
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Los Angeles, CA
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Changing the shape of health care
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Collaboration * Innovation * Impact
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Design, develop and pilot new programs that will
serve as replicable models of care
The Importance of Evidence-based Programs
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National movement.
Tested models or interventions that directly
address health risks.
“With our Evidence-Based Prevention Program, we
are taking health promotion and disease
prevention to a new level and positioning the
aging network as a nationwide vehicle for
translating research into practice.”
-Josefina Carbonell, 2004
Medication Management Project Purpose:
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Partners in Care Foundation, San Fernando, CA, USA is
conducting a multi-phase study to apply evidence-based
Medication Management to MSSP programs first in Los
Angeles County and then disseminate the program state and
nationwide.
Identify the prevalence of potential medication problems
identified in high-risk older adults receiving Medicaid waiver
care-management services at home.
Improve client health and safety by managing medications
Evaluate client and program-level outcomes, including
pharmacist consultation recommendations.
Why Use Care Managers?
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Focused on maintaining health status, delaying
institutionalization, and improving linkages with medical &
community resources
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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 diverse clients
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Linguistically and culturally competent staff
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CM a significant investment of public funds
Snapshot: Evolution of
Medication Management Program
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Hartford Phase 1993-2003 HOME HEALTH AGENCY
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AOA Evidence-Based Prevention Initiative, 2003-2007
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Randomized controlled trial to improve medication use;
developed, tested, disseminated and adopted
Community-Based Medication Intervention
Model successful in Medicaid waiver programs
Next Phase, 2006–2010, Hartford Foundation
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Taking meds management statewide first then nationwide
in care management!
Medication Management Project Rationale
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Patient Safety
► Medication errors are serious: there are at least 1.5 million preventable
adverse drug events (ADEs) that occur each year; 7,000 deaths per year
due to ADEs. 1,3
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They are frequent: Studies estimate up to 48% of community dwelling
older adults have medication-related problems 2
They are costly: The cost of drug-related morbidity and mortality for
seniors exceeds $170 billion (includes hospital admissions and long-term
care admissions) 2
They are preventable: At least 25% of adverse drug events in
ambulatory settings are preventable.
Olmstead Act: MSSP Equity issue - Pharmacist review is mandated for all
Skilled Nursing Facilities and medication review for ICF, ADHC
Medicare Drug Act: Medication Therapy Management provision for highrisk seniors
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.
Evidence-Based Origins
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Hartford/Vanderbilt Study to discover the prevalence of medication
errors and improve medication management among Medicare
beneficiaries aged 65+ receiving home health services.
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Developed by Vanderbilt University researchers & the Visiting Nurse
Assoc-LA (now Partners) and Visiting Nurse Services, NYC in the mid1990s (funded by the John A. Hartford Foundation)
Randomized, controlled trial proved the efficacy of the Medication
Management Model in home health agencies
The model used a pharmacist-centered intervention to identify & resolve
medication errors
Results: Up to 19% had potential medication errors using criteria
developed for home health
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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
“Your condition has no symptoms or health risks,
but there is a great new pill for it.”
Medication Risk Assessment Screening
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As part of usual care RN care managers collected clients’
medications lists and clinical indicators (vital signs, falls, dizziness
and confusion)
Medication lists were screened by a consultant pharmacist using
Home Health Criteria that address 4 potential problem types:
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unnecessary therapeutic duplication
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cardiovascular medication problems
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use of psychotropic drugs in patients with a reported recent fall
and/or confusion
use of NSAIDs in patients at high risk (80+, using corticosteroids
or anti-coagulants) of peptic ulcer complications.
Intervention – From Alerts to Action
Medications entered
into computerized
screening system
(MSSPCare)
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
MSSPCare
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
(MSSPCare)
Role of the pharmacist
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Reviewed medication list according to study criteria
Screened alerts to confirm true problems in light of
diagnoses, symptoms, other medications, etc.
Assisted with complex cases, particularly when there is a
home safety or frequent resource utilization issue;
Communicated with a client’s MD(s) to request reevaluation.
Occasionally identified other medication-related
problems – outside of protocols.
Population Characteristics:
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615 clients screened at 3 Medicaid waiver sites in LA County
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65+
certifiable for skilled nursing facility placement
Dually eligible (Medicare & Medicaid)
Average age: 81 (65-108)
 Female: 80%
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Hospitalization, SNF, or ER in last year? ~ 38% yes
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Falls in last 3 Months ~ 22%
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Dizziness ~ 27%
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Confusion ~ 31%
Lived alone ~21%
 Mean # of medications: 8.76
► 12+ medications – 22%
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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
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)
Potential Medication Problems by Type
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49% of clients had at least one potential
medication problem (N=299)
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24.2% w/ therapeutic duplication (N=
149)
14.3% w/ inappropriate psychotropic
medications (N=88)
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14.1% w/ cardiac problems (N=87)
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12.8% w/ inappropriate NSAIDs (N=79)
# of potential problems increases with
# of medications taken
80%
All
Problems***
60%
2+
Problems***
40%
Therapeutic
Duplication***
20%
Psychotropic
w/ Falls*
0%
1-3
4-6
7-9
10-11
12+
# of Medications
*p<.05, **p<.01, ***p<.001
Improvement after intervention
Medication Problems and Change Rates at 3-Month Follow-Up
MSSP Sample
Screened (N=615)
% Prevalence
Medication Change
(N=162)
Medication Problem
N
N
% Change
All confirmed problems
162
26.3%
99
61.1%
Therapeutic Duplication
79
12.8%
49
62.0%
Psychotropic – All
59
9.6%
32
54.2%
-Confusion
34
5.5%
23
67.6%
-Falls
37
6.0%
16
43.2%
Cardiovascular Problems
24
3.9%
11
45.8%
NSAIDs
44
7.2%
22
50.0%
Results:
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Almost 50% had at least 1 potential medication
problem, compared to 19% in original home health
sample
All problem types had at least 2x prevalence of home
health sample
The highest problem prevalence was unnecessary
therapeutic duplication
Greatest predictor of problems:
# of medications
Waiver Staff Perspectives on Project
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Overall + responses to intervention & translation
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Key differences
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Nurse / Social Worker perspectives
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Experience with EBP implementation
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Location of care managers
CM Feedback on Project Benefits
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“Identify risky meds & duplication”
“Informing clients or families of potential side
effects”
“Increased teaching on meds, side effects, and
therapeutic effect which is good practice in patient
care”
“As a social worker I became aware of potential
dangers of or complications of some medications; I
now look at all medications my clients are taking”
CM Feedback on Project Challenges
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“No or slow response from the doctor. Many clients like
to keep all meds including those they were taken off,
making it very confusing. It can take a long time to
address a med problem”
“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
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High prevalence of potential problems for those at risk
for institutionalization suggests a need for more
systematic medication management in communitybased programs
Those with confirmed medication problems benefited
from a medication management improvement
intervention that includes a pharmacist consulting with
care managers & physicians
Care managers experienced satisfaction from having an
effect on client health and safety by helping manage
medications
Lessons Learned from Study
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Need for a computerized medication risk assessment and
alert system
Hybrid nature of MSSP presented challenges
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MD Communication
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Scope of Practice
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Clinical issues e.g. cardiac assessment
Agency readiness is essential for success
Indicators of Agency Readiness
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There must be a “felt need”
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A sense of the importance and urgency of the problem
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It feels important enough to deserve one’s effort.
There must be a champion
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Pull others along, learn systems, mentor others, serve as an
example, and cheerlead when there are successes.
There must be underlying stability
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Resources viewed as adequate,
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Staff turnover minimal
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Recovery time since last big change.
Implementation Experience
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Start small
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Champion & small team
New enrollees only
Use community pharmacy
resources creatively.
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Changing care management
practice.
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Ongoing training
Staff mentor each other
Staff choice in design options
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Leadership emphasizes the
importance of follow-through;
Clear policies and protocols
Rewards, challenges, contests
Help with routine data entry
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Pharmacy students under the
supervision of their professor
Local community pharmacists
that serve care management
clients.
Future – Part D Medication
Therapy Management
Best ways to communicate
with physicians.
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Usually FAX
Pharmacist, nurse, or care
manager
Medication Management Tools
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Tracking and recording medication alerts in an
automated system
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Medication intervention protocols
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Health assessment
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Vital signs
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Progress notes
Sustaining the Program
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Provide ongoing support and education for staff
Train new staff members in orientation
Arrange for pharmacist consultant
Conduct surveys and other continuous quality
improvement procedures to 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
Next steps for the project:
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More widespread application of the model program
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Additional 4-year funding from the John A. Hartford Foundation
Test and demonstrate the feasibility of the program targeting
frail and poor older adults statewide
Disseminate nationwide
In collaboration with RTZ Associates, implementing a
computerized risk assessment screening alert system
and protocol
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The National Institutes of Health has chosen RTZ to develop an
information system for community long-term care across
waiver programs.
Who can participate?
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Care programs that collect medication and
clinical information and can arrange for a
pharmacist can implement using our toolkit.
At this time there are two absolute prerequisites
for implementing the MMIS as part of our
demonstration project:
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you must be a Medicaid waiver program for elders
your care managers must be using a computerized
client assessment system.
What does it take to succeed ?
 An organization dedicated at every level to providing
high-quality health care for waiver clients
 Staff who are open to enhancing their standards or
scope of practice for the benefit of client health and
safety
 A culture that values continuous quality improvement
and evidence-based practice
 Staff use of computerized client assessment system.
What does it take to succeed ?
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Working relationships with health care consultants
capable of advising on medication safety
(pharmacist, physician or nurses).
Ability to work with clients, families, and physicians
to resolve medication problems
Able to spend $100/month for online medication
screening tool.
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
Detailed manuals, protocols, and handouts on medication
management
Use of a modestly-priced, secure on-line medication
management tool
Personalized consultation to adapt the intervention for
your agency’s needs
Site support resources to help defray initial costs
Enhanced education and training for staff on medication
use and problems among older adults
National prominence as part of the vanguard in bringing
this AoA evidence-based disease prevention program from
its pilot phase in California to new states.
Next Steps:
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For more information: www.homemeds.org
Identify a consulting pharmacist who can
screen medications and help care managers
with follow through
Contact the Medication Management
Improvement System team c/o Mira Trufasiu
at 818.837.3775 x112, [email protected]
Acknowledgements
Collaborators
Partners in Care Foundation
Dennee Frey, PharmD
June Simmons, LCSW
Mira Trufasiu, MSG
Sandy Atkins, MPA
Jennifer Wieckowski, MSG
Susan Enguidanos, PhD
Huntington Hospital Senior Care Network
Neena Bixby, LCSW
Eileen Koons, MSW
Lois Zagha, MA
Pat Trollman, LCSW
USC Andrus Gerontology Center
Gretchen Alkema, PhD
Kathleen Wilber, PhD
Funding Support
Administration on Aging
Evidence-Based Prevention
Initiative (Grant No. 90AM2778)
John A. Hartford Foundation
► Medication Management
Intervention Dissemination
► Doctoral Fellows Program
in Geriatric Social Work