Download Vital Aging Research and Demonstration Center

Medication Management: A
New Standard for Care
Management Programs
Sandy Atkins
Project Director
Mira Trufasiu
Project Manager
Partners in Care Foundation

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 is conducting a multi-phase study to
apply evidence-based medication management to
Medicaid waiver care management programs in California
and nationwide.
Identify the prevalence of potential medication problems
in high-risk older adults receiving Medicaid waiver caremanagement services at home.
Improve client health and safety by managing
medications
Evaluate client and program-level outcomes.
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 and care about their clients
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Linguistically and culturally competent staff
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Knowledgeable of available resources
Evolution of Medication
Management Program
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Hartford Phase 1993-2003 HOME HEALTH AGENCY
► Vanderbilt Univ. randomized controlled trial to improve
medication use; developed, tested, disseminated and
adopted
AOA Evidence-Based Prevention Initiative, 2003-2007
► Community-Based Medication Intervention
► Model successful in Medicaid waiver programs
Next Phase, 2006–2010, Hartford Foundation
► Taking meds management statewide first then nationwide
in care management!
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
Medicare Drug Act: MTM provision for high-risk 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 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
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
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
“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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RN care managers collect clients’ medications lists and clinical
indicators
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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;
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Falls, dizziness, or confusion possibly caused by inappropriate
psychotropic drugs;
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Inappropriate use of non-steroidal anti-inflammatory drugs
(NSAIDs) in those with risk factors for peptic ulcer.
Intervention – From Alerts to Action
An Alert is
Generated
Care Manager
(CM) confirms
med is currently
used by client
MD response goes to
Pharmacist. CMs
document
. updated med
list and CM files in chart.
CM emails alert
to Pharmacist
Pharmacist tracks
status of
recommendations
Pharmacist creates
recommendation
letter for MD &
documents in
MSSPCare
Recommendations
& med lists are
sent to MD
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
Evidence of Effectiveness
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615 clients in 3 Medicaid waiver sites were screened
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49% (N=299) had potential medication problems.
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Record review and consultation with the client led the pharmacist to
recommend:
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Continue the medications - necessary for pain/symptom control;
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Collect more information - vital signs and other clinical indicators
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Verify dose and frequency with which the client was taking the
medication and revise the medication list accordingly; or
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.
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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~50% had at least 1 potential medication problem Vs.
19% in original home health sample (HH)
All problem types had at least 2x prevalence of HH
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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There must be a champion
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A sense of the importance and urgency of the problem
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
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Train new staff members in orientation
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Arrange for pharmacist consultant
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Identify best practices and problems.
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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.
What does it take to succeed ?
 Staff open to enhancing scope of practice for client
health and safety
 A culture that values continuous quality
improvement and evidence-based practice
 Staff using computerized client assessment system
 $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
Use of a modestly priced, secure on-line medication
management tool
Personalized consultation to adapt the intervention
Site support resources to help defray initial costs
Training on medication use and problems among
older adults
National prominence as part of the vanguard in
bringing this AoA evidence-based disease prevention
program
National benchmark comparisons
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
Care managers must be using a computerized client
assessment system
Sites must also:
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Collect medication and clinical information
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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 November
Identify a consulting pharmacist who can screen medications
and help care managers with follow through
Contact the Medication Management Improvement System
team:
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Mira Trufasiu, Project Manager - 818.837.3775 x112,
[email protected]
Sandy Atkins, Project Director - 818.837.3775 x111,
[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