Transcript Vital Aging Research and Demonstration Center

New Care Management
Strategies to Improve Health
Outcomes
June Simmons
CEO/President
Dennee Frey, PharmD
Project Director
Jennifer Wieckowski, MSG
Project Manager
Mira Trufasiu, MSG
Project Associate
Evidence-based Prevention Initiative
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Community-based Medication Management Intervention
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Healthy Moves for Aging Well
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Guided by the Center for Healthy Aging, NCOA

Evaluated by the USC Andrus Gerontology School
Goal: Lessons learned from evidence-based interventions
will inform future Disease Prevention Health Promotion
programming nationwide
Care Management Variables
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Targeting Criteria: Influences eligibility and outreach
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Gate keeping Mechanisms: Authorize services or coordinate
what exists or can be arranged
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Financing Reimbursement: Older Americans Act, Medicaid, etc.
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Organizational Auspices: Public, Non-profit, Private-pay
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Staffing: Individuals or teams and disciplines involved: MSW, RN
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Core Functions
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Outreach
Screening and Intake
Comprehensive assessment
Care Planning
 Service Arrangement
 Monitoring
 Reassessment
Enhancing Care Management
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MSSP (Multipurpose Senior Services Program) is a California
Medicaid Waiver care management program with 41 MSSP
sites serving 12,000 diverse frail elders on any given day
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Eligibility Qualifications
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Age 65+/Medicare enrollee
Resides within a program service area
Certified for placement in a nursing facility (SNF or ICF)
Medicaid recipient with no co-payment requirements
Why use Care Managers?
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Ready access to frail, low-income & diverse seniors
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Established rapport with diverse clients
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Focused on maintaining health status, delaying
institutionalization, and improving linkages with medical &
community resources
Linguistically and culturally competent staff
CM programs represent a significant investment of public
funds
Medication Management Intervention
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Partners in Care Foundation, San Fernando, CA, is conducting
a 3-year U.S. Administration on Aging (AoA) funded study to
apply a previously tested evidence-based Medication
Management Model to MSSP programs first in Los Angeles
County and then disseminate the program statewide.
The goal of our Medication Model is to identify, prevent, and
resolve medication errors among community-dwelling high-risk
seniors receiving care management services
“Your condition has no symptoms or health risks,
but there is a great new pill for it.”
What do we know about medication errors?
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Medication errors can create costly and serious, even
catastrophic, health problems:
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5th leading cause of death for older adults1
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7,000 deaths per year due to adverse drug events1
Studies estimate up to 40% of community-dwelling
seniors have medication-related problems2
About 1/5 of community-dwelling elderly use at least 1
of 33 drugs considered potentially inappropriate 2
1.
Institute of Medicine. (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.
Make him take 16 of these a day until we feel
better about what we’re doing to him!
Medications Management Project Rationale
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Patient Safety
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Medical errors
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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 high-risk seniors
Medication Management Program: EvidenceBased Origins
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Funded by John A. Hartford Foundation, Inc. in mid-90s
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Multiphase study to identify the prevalence of medication errors
and improve medication management among Medicare
beneficiaries receiving home health services.
Developed by Vanderbilt University researchers & the Visiting
Nurse Assoc-LA (now Partners) and Visiting Nurse Services, NYC
To test the efficacy of Medication Management Model in home
health agencies the team undertook a randomized, controlled
trial intervention to improve medication use
The Model used a pharmacist-centered intervention to identify &
resolve medication errors
Results of Evidence-Based Study
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Results: Up to 30% had medication errors using the Beers
criteria and Home Health criteria developed for the study
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Medication use improved in 50% of intervention
patients, compared to 38% of controls (p=.05).
Improvement was greatest for therapeutic duplication
(71% vs 24% p=.003)
Cardiovascular problems (55% vs 18%, p=.02)
Conclusion:
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The trial demonstrated that medication errors can be
avoided and prescribing practices can be improved in
the geriatric population.
Based upon the evidence, what are the core
features of an effective program?
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Guidelines established by an expert panel for resolving high-risk
medication problems among clients receiving in-home services:
► unnecessary therapeutic duplication
► cardiovascular medication problems
► use of psychotropic drugs in patients with a reported recent
fall and/or confusion
► use of non-steroidal anti-inflammatory drugs (NSAID) in
patients at high risk of peptic ulcer complications.
A consultant pharmacist assisting the care management team to
assess and resolve potential medication problems.
Computerized medication risk assessment screening and alert
process in collaboration with RTZ software.
MSSP Implementation Phase
1. Care Managers conduct a medication assessment
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Enter list of medications into computer database
RTZ MSSPCare software program analyze data using
the intervention’s computerized algorithm for risk
assessment.
2. Potential medication problems identified
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A. Pharmacist reviews the medication regimen &
Consults with MSSP staff to develop care plan.
B. Future: Alert of potential problem to CM and
protocol implemented
MSSP Implementation Phase
3. Pharmacist or CM
contacts the
physician
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to present the
problem
discuss the
medication
regimen
obtain follow-up
orders
“If you’re stumped, why not write
an illegible prescription and hope
the pharmacist comes up with
something?”
MSSP Implementation Phase
4. The CMs assists the client with:
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medication changes, adherence issues
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follow-up periodically
5. Repeat procedure if a change in medications is
identified in the follow-up contact.
Sample Characteristics (N=615)
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Data collected from 6/2004-12/2005
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615 clients screened in 3 LA County MSSP sites
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Average age ~ 80 years (SD=7.76); 80% female
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24% Caucasian, 39% African-American, 24% Latino/a,
8% Asian/PI, 5% Other
42% live alone
Medication Problem Prevalence
20%
17.6%
15%
12.7%
11.9%
MSSP
10%
6.9%
5%
Home Health
6.4%
4.7%4.3%
4.0%
0%
Therapeutic
Duplication***
Inappropriate
Psychotropic
Meds***
Inappropriate
NSAIDs***
Cardiac
Problems
Medication Problem Prevalence
(N=615)
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Average # of medication problems ~ .53 (SD=.82)
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37.5% with at least 1 medication problem
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19% in original Home Health sample
12% with 2+ problems; 3% with 3+ problems
Clients w/ 9+ medications have 2x greater odds of
medication-related problems that those with under 9
meds
Lessons learned :
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Most Care Management staff agree: Improving medication
management is important.
MSSP is a hybrid social/medical care management program.
This presented some challenges in adapting the model from
the medical Home Health model.
Model problem focus should be modified for future use and
should consider under-treatment (eg. depression and pain)
Scope of practice issues regarding medication management
screening and follow-up, especially regarding cardiac
screening such as taking blood pressure, assessing vital
signs.
Screening Tool
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Despite challenges in computerizing medication risk
assessment screening…it can work and can be a cost
effective tool!
RTZ and Partners are refining the product for widespread
use as part of an NIH grant.
Care managers can be “alerted” to potential problems
and implement the intervention quickly
Screening Tool Sample
Management, Joe
9999
Alert type risk factor: Risk of/ Recent Falls
VS/Event Date
Temazepam 30mg Tablets
3/11/2005
Alert type risk factor: Hypertension
VS/Event Date
Vital Sign Record
Atenolol Tablet USP
12/19/2004
180/100
Cardizem Tablet
12/19/2004
180/100
Alert type risk factor: Pulse Rate
VS/Event Date
Vital Sign Record
Lanoxin Tablet
3/11/2005
50 is <= 55
Vital Sign Record
Therapeutic Duplication
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The intervention can be focused and simplified to fit
agencies’ needs
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Goal of therapy: Discontinue duplicate drug
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“Low hanging fruit”
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Can be effectively identified with a computerized
risk assessment screening and alert program
What do participants say?
“The pharmacist I spoke to
was very helpful in sorting
out my medications.”
“I was on too many
medications and
didn’t know what
they were for. I don’t
have to worry about
that any longer.”
Products
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Improving Medication Management
in Home Care Issues and Solutions
Toolkit
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check www.homemeds.org for
updates
Healthy Moves for Aging Well
Funders & Sponsors
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Originally funded by the John A. Hartford Foundation
Currently funded by:
• Archstone Foundation
• The California Endowment
• UniHealth Foundation
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Sponsored by the AoA Evidence-based Prevention Initiative
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Guided by the National Council on the Aging
Needs Assessment
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Few older persons engage in regular physical activity
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31% of aged 65-74
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23% of aged 75+
Average decline in physical functioning of 10% each
decade between ages 60 & 90
Active adults experience 1/2 as much loss in physical
functioning
Physical activity can extend life expectancy 28% for frail
elderly
Evidence-Based Study (Rikli & Jones, 1999)
SENIOR FITNESS TEST
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Nationwide study conducted to establish normative
physical performance scores for older adults
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Ages 60 to 94
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7,183 participants
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5,048 women & 2,135 men
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267 sites
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21 states
Pilot Results
76% Client Retention Rate
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4 Care Management Sites
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Senior Care Network, Huntington Hospital
Jewish Family Service
AltaMed Health Services Corporation
Partners in Care North
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Number of Clients = 49
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Average Age = 78 years
2nd Generation of Healthy Moves
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4 MSSP Sites
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Jewish Family Service of Los Angeles- 700 clients
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Partners in Care South Central Site- 400 clients
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AltaMed Health Services Corporation- 603 clients
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Senior Care Network at Huntington Hospital- 440 clients
Evaluation Plan
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Does intervention change care manager and client behavior?
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Does intervention improve client’s health outcomes?
•
Pain, Depression, Falls, and Physical Functioning
HOW DO THE MOVEMENTS
APPLY TO LIFE?
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Upper body endurance &
strength
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Holding grandchildren
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Increases blood circulation to
manage/ prevent ankle swelling
Increases ability to lift toes to avoid
tripping on rugs, steps & curbs
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Increases ankle flexibility
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Rising from a chair or toilet
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Getting in & out of the car
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Getting on & off public
transportation
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Strengthen lower legs
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Getting to toilet
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Shopping for groceries
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Walking outside to get ride
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Getting the mail
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Lifting/carrying laundry & groceries
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Pouring a drink from a carton
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Reduces fall risk
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Arm Curl
Ankle Point &
Flex
Chair Stand
Step-In-Place
Client Goal Setting
Holding
Grandchild
Rising From
a Chair or
Toilet
Getting
the Mail
Lifting Toes
to Avoid
Tripping
Doing Your
Own Grocery
Shopping
Pouring a
Drink From
a Carton
Your Goal
Walking
in the
Home
Behavior Change Education
Brief Negotiation Curriculum
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Teaches skills needed to incorporate physical activity
into clients’ daily routines
Trusts the natural change potential in every client
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Client self-assessment of readiness for change
Identifying goal for behavior change results
Prevention of relapse into sedentary behavior
How ready are you to consider increasing your physical activity?
0
1
Not Ready
2
3
4
5
6
Thinking About It
7
8
9
10
Ready
Falls & Fear of Falling
Does a fear of falling prevent you from performing
daily activities?
1. None of the time 2. Some of the time 3. Most of the time 4. All of the time
How many falls have you had in the last 3 months?___
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Were you injured from any fall?
Yes
No
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What were you doing when you fell?_________
Pain Scale
Please rate, on average, the level of pain you have
experienced in the past 2 weeks.
0
1
No Pain
2
3
4
5
6
7
8
9
10
Excruciating Pain
Depression Scale
In the last month I have felt depressed or anxious:
1. None of the time
2. Some of the time
3. Most of the time
Protocol
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Care managers teach intervention
Coaches monitor progress and reinforce the
change by phone
Care managers & coaches follow-up with clients at
regularly scheduled phone calls and visits
Testimonials
“I love doing my exercises because I can just sit in my
chair and work-out! The level is perfect”– 96 year
old
“I started to walk around my house on my own because
I feel so great!”- 96 year old
“My ankle swelling has reduced since I started doing
the ankle point & flex”. – 83 year old
“At my age, there is not a lot doctors can do for all my
pains, but I feel really good. My back feels great!”
–70 year old
Products
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Healthy Moves Website: www.picf.org
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Toolkit
Evaluation Materials
Client and Care Manager Materials
Client Testimonials
Healthy Moves Video
Multiple Languages: English, Spanish,
Russian, Korean, Chinese, Armenian & Farsi
Challenges in Delivery System Change
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Liability & Concerns
Workload
Reinforcement of staff training
Social Worker Bias
► CM scope of practice
► CM resistance to change
Program sustainability
Reimbursement for consultants’ services
Lessons Learned:
Changing Care Management Practice
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Changing practice standards & shifting staff
responsibilities almost always elicits a learning curve.
Intervention must fit practice environment- simple &
succinct
Changing behavior requires supervisory buy-in
Agencies must be “ready” to adopt a new innovation—
staff shortages complicate demands on staff
Lessons Learned Cont’d
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Joint planning with staff & supervisors identifies
valuable methods to create change (i.e. focus
groups, questionnaires)
Intervention must be marketed in terms of value to
staff
Client testimonials generate enthusiasm for adoption
Volunteer recruitment requires new partners &
innovations
Contact Information
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June Simmons, [email protected]
Jennifer Wieckowski, [email protected]
Mira Trufasiu, [email protected]
Partners in Care Foundation
732 Mott Street, Suite 150
San Fernando, CA 91340
818-837-3775
www.picf.org; www.homemeds.org