Transcript Vital Aging Research and Demonstration Center

Implementing a Medication Management
Intervention in Care Management Programs
June Simmons
CEO
Mira Trufasiu
Project Associate
Sandy Atkins
Project Director
Authors:
J. Simmons, J. Wieckowski,
M. Trufasiu, G. Alkema,
K. Wilber, D. Frey
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.
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!
Medications 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.
Medication Management 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.”
AoA Evidence-Based Program: Population
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The study was conducted from June 2004 – January
2006 in 3 Los Angeles-area Multipurpose Senior
Services Programs (MSSP), serving dually eligible
enrollees
Eligible clients:
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newly admitted and/or current enrollees
65+
certifiable for skilled nursing home placement
live at home with waived services
We hypothesized that our targeted client base might
be at higher risk for medication problems, due to
multiple chronic diseases and medical conditions.
AoA: 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 conducting a
focused review using the 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 anticoagulants) of peptic ulcer complications.
A computerized medication risk assessment screening and alert process
using the medication list and clinical indicators was developed and
piloted for future use.
Medication
data collected
& entered in
computerized
database.
Computerized
risk
assessment
screening of
medications.
Care Manager
and pharmacist
alerted to
potential
problems.
The Medication Management Model
Follow-up by
care
manager/
consultant
pharmacist
MD contacted
as needed.
1. Additional
data collected
2. Problem
verified
Positive
Negative
Follow-up
periodically
with the client.
False
Positive: No
medication
problem.
AoA: Role of 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 potential medicationrelated problems warranting review by the consultant
before MD is contacted.
AoA Preliminary Results:
Population Characteristics
615 clients screened at 3 Medicaid waiver sites in LA County
►Average age: 81 (65-108)
►80% female
►Ethnicity:
• Caucasian – 24%
• African-American – 39%
• Latino/a – 24%
• Asian/Pacific Islander – 9%
• Other – 4%
 Mean # of medications: 8.76
• 12+ medications – 22%
 Hospitalization, SNF, or ER in Last Year? ~ 38% yes
 Falls in Last 3 Months ~ 22%
 Dizziness ~ 38%
 Confusion ~ 31%
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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 (29% of Total Sample)
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)
14.1% w/ cardiac problems (N=87)
12.8% w/ inappropriate NSAIDs (N=79)
Number of problems increases with
number of medications taken
Figure 3.3: Confirmed Medication Problems by
Number of Medications (N=615)
80%
70%
All
Problems***
% of Sample
60%
2+
Problems***
50%
40%
Therapeutic
Duplication***
30%
Psychotropic
w/ Falls*
20%
10%
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
Strongest predictor of potential
problems: # of medications
Conclusions
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Medicaid nursing-home-eligible seniors had over 2x prevalence of
potential medication problems compared to a home health
sample of the same average age
This increased prevalence of potential problems for those at risk
for institutionalization suggests a need for more systematic
medication management improvement processes 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 AoA
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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
Agency readiness is essential for success
MSSPCare: Medication Management Tools
Tracking and Recording Medication alerts in an
our automated system, MSSPCare.
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MSSP Sites who utilize MSSPCare can
participate in the study and get more in-depth
information about medication alerts.
MSSPCare Screening Tools
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Medications/Interventions
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Health Assessment
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Vital Signs
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Progress Notes
Recording Medications/Interventions
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Care Managers use
full or partial name
to search the
expanded
medication library
for the medication
they want to add.
As they enter
medications, the
system tracks
potential conflicts.
Health Assessment
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Questions on the
initial Health
Assessment help
determine risk
factors
Vital Signs
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Vital signs records
screen for risk
alerts like age and
blood pressure.
Standard rules are
set in the system
and each alert is
tracked.
Progress Notes
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Staff record falls
in Progress
Notes
Falls are
compared
against
medications
entered to
generate alerts.
Alerts
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Alerts include:
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Duplication of
Medication or
Medication class;
Risk for Hypertension
or blood pressure;
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Risk for confusion;
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Risk for falls; and
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Maximum dosage per
administration or per
time period.
Reporting on Alerts
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MSSPCare generates different reports to track alerts
per client and across all clients.
Reports can be run with:
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Summary Counts per time period;
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Detailed information for an individual client; and
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By PCM/ caseload.
Intervention: From Alerts to Action
Medications entered
into MSSPCare
Physician informed of
confirmed problems:
-Letter or
-Phone call
from
-Care manager or
-Pharmacist
CM Follows Up with
Client:
Review medications to
find out if there has
been change
ALERT:
Possible
therapeutic
duplication
MSSPCare
Produces Alerts
regarding potential
medication problems
Confirmed
Problem:
2 Beta
Blockers
Care Manager reviews
meds with client:
-Are you really taking
both?
-How much?
-How often?
-Why?
Pharmacist reviews
suspect medications in
light of:
-Who prescribed
-Diagnoses
-Vital signs
-Other symptoms
CM documents in
MSSPCare:
-client discussions
-pharmacist consultation
-notification of MD
-any change in problem
medications
Client is
taking both
regularly
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.
Next Steps for MSSPCare Clients
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Study Participants
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All participants receive benchmark reports comparing
performance on a variety of measures with the average of
other sites
Controls can participate in intervention after six months
Experimental participants also get:
• Enhanced medication problem alert features of MSSPCare
• Access to consulting pharmacist if needed
• Complete toolkit
• Comprehensive training
• Technical assistance
• Ongoing support
Next Steps for Study Sites
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Participating sites need to:
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Provide baseline operational information, ongoing site data,
and feedback
Attend trainings as required on the new system functionality
and about roles and procedures for implementing the
medication management intervention.
Use the system’s medication library, alert, and assessment
features consistently.
Implement at least two medication management protocols
over six months (e.g. therapeutic duplication).
Follow through on medication-related alerts and document
actions taken and their outcomes
Use PICF pharmacist or have own consulting pharmacist
Next Steps:
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Go to www.homemeds.org for complete
toolkit
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]