Transcript Vital Aging Research and Demonstration Center

Medication Management Intervention
Enhancing medication management in
community-based Medicaid waiver
care management programs
Authors:
J. Simmons, J. Wieckowski,
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
Session Objectives
1)
Describe the Medication Management Intervention
including the role of care managers.
2)
Identify lessons learned when implementing a new
intervention in existing care management programs.
3)
Present findings including the program’s impact to
identify medication problems for frail older adults
WHAT DO WE KNOW ABOUT
MEDICATION ERRORS?
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They are serious: 5th leading cause of death for older
adults; 7,000 deaths per year due to adverse drug
events 1
They are frequent: Studies estimate up to 40% of
community dwelling older adults
They are costly: The cost of drug-related morbidity
and mortality for seniors exceeds $120 billion
(includes hospital admissions and long-term care
admissions) 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.
“Your condition has no symptoms or health risks,
but there is a great new pill for it.”
Aggressive Advertising by Drug Companies
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>$4 billion in consumer advertising last year
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Americans spend about $190 billion in Rx
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Heavily promotes drugs that treat symptoms rather
than illnesses, “quick fixes”
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Sleeping pills, Ambien
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Cholesterol-lowering drugs, Lipitor
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Viagra
Make him take 16 of these a day until we feel
better about what we’re doing to him!
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!
Care Management Variables
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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)
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California Medicaid Waiver care management program
with 41 MSSP sites serving 12,000 diverse frail elders on
any given day
Eligibility Qualifications
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Age 65+/Medicare enrollee (dually eligible)
Resides within a program service area
Certified for placement in a nursing facility
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
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
What is the meds management intervention ?
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Computerized risk assessment screening and alert process
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Guidelines that target high-risk medication problems:
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unnecessary therapeutic duplication
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cardiovascular medication problems
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use of psychotropic drugs with fall and/or confusion
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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
Home Health Setting: The Evidence
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Results: Up to 30% had medication errors
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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
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 medication management can be
improved
Medication
data collected
& entered in
computerized
database.
Computerized
risk
assessment
screening of
medications.
Follow-up by
care
manager/
consultant
pharmacist
Care Manager
and pharmacist
alerted to
potential
problems.
1. Additional
data collected
2. Problem
verified
Positive
Negative
MD contacted
as needed.
False
Positive: No
medication
problem.
Preliminary Results from AoA:
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615 clients screened at 3 Medicaid waiver sites
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Average age: 80; 71% female
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Average # of medications: 10.73
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9+ medications – 65%
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12+ medications – 37%
More Findings…
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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
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14.3 % w/ inappropriate psychotropic medications
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12.8 % w/ inappropriate NSAIDs
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14.1 % w/ cardiac problems
Overall these results are DOUBLE the prevalence of
the Home Health Study
Medication Problem Prevalence
(Preliminary Findings)
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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
Health Status (Preliminary Findings)
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Hospitalization, SNF, or ER in Last Year? ~ 47% yes
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Average # of Medications ~ 10.73 (SD=4.7)
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Falls in Last 3 Months ~ 35.8%
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Dizziness ~ 37.7%
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Confusion ~ 35.8%
Improvement In Medication Use at
3-Month Follow-Up (Preliminary Findings)
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26% of clients had at least
one confirmed medication
problem (N=162)
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12.8% w/ therapeutic
duplication (N= 79)
9.6% w/ inappropriate
psychotropic medications
(N=59)
7.2% w/ inappropriate
NSAIDs (N=44)
3.9% w/ cardiac problems
(N=24)
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61% of the intervention group
experienced medication
improvement (N=99)
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65.8% of therapeutic
duplication (N=52)
64.4% of inappropriate
psychotropic medications
(N=38)
68.2% of inappropriate NSAID
use (N=30)
54.2% of cardiac problems
(N=13)
Lessons Learned
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Medicaid waiver frail elders seem at especially high risk
for errors
Overall they have a higher prevalence of most
medication problems than original Home Health study
Based on this, there is a need to improve medication
management in this population.
A computerized medication risk assessment alert system
can assist care managers to identify therapeutic
duplication
Lessons Learned
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MSSP is a hybrid social/medical care management program,
presenting 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 cardiac screening such
as taking blood pressure, assessing vital signs.
Final Thoughts
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Most Care Management staff agree: Improving
medication management is important.
Readiness assessment is essential before site
implementation
For more information, visit…
www.homemeds.org
www.picf.org