Title: Medication Therapy Management in a Memory Care Clinic A Cornerstone for Care JoanThralow OTRL Dean S
1Medication Therapy Management in a Memory Care
Clinic - A Cornerstone for Care JoanThralow
OTR/LDean Schmiedt Pharm. D.Memory Care Clinic
St. Cloud, Minnesota
2MEMORY CARE CLINIC
- Began in 2004- Several agencies identified the
need for early diagnosis - Central Minnesota Council on Aging
- Alzheimers Association
- St. Benedicts Center
- Mid-Minnesota Clinic/Centra Care
- Health Partners
- Stearns, Benton, Sherburne, Wright Counties
- St Cloud Area Faith in Action
3The Importance of Early Identification
- GOAL
- Increase rates of diagnosis and treatment at
earlier stages to enhance quality of care and
caregiver support
4Memory Disorders
- Dementia the loss of cognitive function
(cognition) due to changes in the brain caused by
disease or trauma. - Dementia is not a diagnosis.
- Cognition is the act or process of thinking,
perceiving, and learning - Cognitive functions that may be affected by
dementia include the following
5Memory Disorders (cont.)
- Irreversible Dementia
- Alzheimers Disease
- Vascular Dementia
- Lewy Body Dementia
- Parkinsons disease
- Huntingtons Disease
- Frontotemporal Dementia
- AIDS Dementia Complex
- Reversible Dementia
- Major Depression
- Delirium
- Metabolic Disorder
- Infections
- Brain tumor and subdural hematoma
6MISSION
The Memory Care Clinic is a community partnership
committed to enhancing the lives of persons
affected by memory disorders through excellence
in care, treatment, support, and education.
7- Memory Care Clinic
- recent name change
- formerly
- Memory Disorders Clinic
8COLLABORATIVE CARE IN THE MEMORY CARE CLINIC
9MEMORY DISORDERS TEAM
- Medical Director
- Nurse Practitioner
- Social Worker
- Occupational Therapist
- Doctor of Pharmacology
- Office Manager
- Executive Director
- Accountant
10Memory Care Clinics Role in the Community
- Assess
- Assist
- Learn
- Teach
11Memory Care Clinic
- Partnership of many community agencies working to
enhance the lives of persons affected by memory
disorders and those who care for them. - Three cornered assessment process
12The Memory Care Clinic assesses
- 3 Cornerstones for Assessment
- Medical assessment.
- Functional assessment.
- Psycho-social assessment.
- Also Assess the Caregiver
- Burden of the care giving.
- Social/emotional capability for caregiving.
- Knowledge about the condition of the patient.
13Memory Care Clinic Staff Assist
- The person with memory loss
- Recommendations resources
- The caregiver of the person with memory loss
- Support education, support groups, coaching
- Information referral
- The primary care physician
- Information recommendations
14Memory Care Clinic
- Provides
- Comprehensive assessment
- Collaboration in care with the patients primary
physician - Recommendations for treatment
- Education and caregiver support
- Community agency referral
- Case management
15MCC has a commitment to LEARN
- Regular review of research literature
- Opportunities for professional education
- Analysis of data gathered through our work.
MCC has a commitment to TEACH
- In-service education for health care
professionals - Internships for students in health professions
- Sharing our knowledge with caregivers
16Memory Care Clinic
- Is a Collaborative Care Model for Clients with
Dementia and their families, serving a broad
community. - Partners with primary care physicians.
- Provides assessment, recommendations for
treatment, education and support for care givers. - Follow-up includes Education, Support Groups
Caregiver Coaching - Is a cooperative community project.
17THE MEMORY CARE CLINIC
- Accepts referrals from family members,
physicians, social service community agencies. - A few individuals self refer.
- Do not need a physician order to come to the
clinic - primary care physician support helps - Assessment is completed in two 2-hour
appointments. - Follow-up after Assessment is very important.
18Funding the MCC
- Start-up funding was provided by
- MN Dept. of Human Services CSSD Grants.
- MN Board on Aging Alzheimers Demo. Grants.
- Medicare, MA, health insurance fund part of
Assessment costs. - Older Americans Act Title III-E covers part of
Caregiver support services. - Board of Directors has fiduciary responsibility.
- Is now a 501(c)(3) Charitable Organization.
- Private donations and other grants.
192009 Funding Sources for The Memory Care Clinic
-
- Government Grants 35
- Insurance Co-pays 18
- In-Kind Contributions 22
- Donations Private Grants 24
- Other Income 1
-
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21Why involve a pharmacist?
- Frequent medication related questions from
caregivers and patients. - Clinic survey identified that approximately 1 out
of 3 patients or their caregivers desired more
assistance with medication issues. - Perception of unidentified medication related
issues. - Medication Therapy Management (MTM) has been
found to be valuable - Insurers may cover MTM under Medicare D and by
the state for MA patients.
22Pharmacists
- Jody Ellingson, Pharm. D.
- Dean Schmiedt, Pharm. D.
- Our background is long term care consulting,
providing medication therapy reviews for a large
number of nursing facilities in central
Minnesota. - We have no role in dispensing medications to
patients.
23Barriers
- The only true barrier to implementation has been
funding and insurance reimbursement for the
program. - The clinic received assistance with funding for
one year via a CS/SD grant.
24Memory Care Clinic Staff
- Have been extremely open, supportive, and helpful
with our integration into the clinic. - We highly value their insights on patients and
caregivers medication related issues. - Clinic staff have been helpful in encouraging
pharmacist reviews for patients felt to be in
need of MTM.
25Integration / Orientation Process
- Orientation to clinics processes and
documentation requirements - Federal and State Provider numbers
- Credentialing with insurance companies
- Followed patients/caregivers through the clinics
assessment process. - Developed pharmacist assessment documentation
process. - Orientation for the clinic staff of our proposed
assessment process and services.
26Pharmacist Integration Into Assessment Process
- Discussion with staff about what approaches would
work best? - Early, late, or after the assessment process?
- Targeted or referred patients or all?
- Paper chart review vs direct meeting with patient
and/or caregiver. - We chose to be flexible and provide pharmacist
services on an as desired/ as needed basis.
27Scheduling
- Decision was made to be flexible to see what
worked best. - Best model for efficiency and cost-effectiveness.
- We have a lot of flexibility in our scheduling.
28Our Goals This First Year
- Clinic integration
- Develop pharmacist assessment process
- Provide both chart and in-person MTM reviews.
- Identify the types of issues identified during
MTM review and their significance. - Document pharmacist findings in clinic chart,
letter to primary physician, and to the
patient/caregiver. - Be an educational resource to caregivers,
patients, and clinic staff.
29Caregiver and Patient Education/Support
- Presentations were made to the clinics
Caregivers Support Group twice. - Well attended, primarily caregivers.
- Lots and lots of questions!
- Many caregivers are well read on medications used
for memory loss. - We emphasize realistic expectations from
medications such as cognitive enhancing drugs.
30Caregiver Support Group Interests
- High level of interest and questions relating to
- Medications that may cause memory impairment.
- Cognitive enhancing medications
- When is it appropriate to terminate cognitive
enhancing medications? - New or experimental treatments.
- Non-traditional / alternative treatments such as
herbal, nutritional, or vitamin products. - Medication adverse reactions
- Behavior, mood, or sleep inducing medications.
31Assessment ProcessIn-Person Review
32In-Person Assessment Process
- Comprehensive review covering all aspects of
medication use. - MTM reviews not limited to memory loss issues.
- Caregivers and patients have been very clearthey
want a total medication review. - Initially, they may have one or two very specific
primary questions or issues. - Often more issues are identified.
33Assessment ProcessHistory Review
- Review past medical history, medication lists,
labs, cognitive testing, plus any relevant
assessments or background information available
in the clinic chart. - Done prior to visit.
- Provides insight about the patient
- Identifies potential issues for review
34Examples of Common Medication Related Problems
- Appropriate Indication
- Medication Effectiveness
- Dose
- Adverse Effects
- Drug Interactions including with food
- Compliance/Adherence/Administration
- Potentially Unnecessary or Inappropriate
medication - Potentially untreated or under-treated
conditions. - Undisclosed medications, herbals, or relevant
nutritional products. - Medication Errors
- Lab Monitoring/Assessment
35Assessment ProcessMedications
- Complete list of medications from
chart/historical information is compared with the
caregivers or patients list. - Frequently, medication regimens have changed from
information provided to the clinic. - Many patients are taking undisclosed
medicationsincluding prescription, OTC, herbal
and nutritional supplements. - Eight of eighteen (44) patients seen in-person
had undisclosed medications, herbals, vitamins,
or supplements.
36Assessment Process Caregiver or Patient Concerns
- We always inquire early in the process if the
caregiver or patient has any specific concerns? - Most common concerns
- Are all these medications needed?
- Could any medications cause memory loss?
- Do these medications work together or could they
interfere with each other? - Specific adverse effect related questions
37Areas for review/assessment
- Does the caregiver/patient
- Understand the indications and goals for each
medication? - Understand medication directions
- Take medications properly
- Indicate any issues with adherence or compliance
- Express concerns over medication effectiveness.
38Adverse Reaction Review
- Potential adverse reactions specifically
reviewed - Unintended weight loss or gain.
- Dizziness
- Confusion/Memory Loss
- Recent or multiple falls
- Sleeping issues
- Abnormal body movements or tremors
- Urinary incontinence or bowel issues
- GI symptoms such as unusual or persistent nausea,
heartburn, or vomiting - Behavioral or Mood issues
- Other
39Ability to pay for medications
- We check if there are any issues relating to
paying for medications. - Medicare D has reduced payment issues.
40Reassurance
- Caregivers and patients often desire reassurance
that - All medications are necessary.
- Medications go together.
- Medications are not the cause of memory loss or
other significant adverse effects. - They are doing the right thing with medications.
41Documentation Process
- Post Visit Documentation for In-Person Includes
- Clinic chart documentation
- Letter with recommendations to physician (s)
- Letter with recommendations to patient / caregiver
42Patients Oct 08 June 09
- Grant goal, initially, was 24 patients / reviews
- We did not see patients until October 08.
- Actual 27 patients/reviews in 9 months
- 9 chart reviews
- 18 in person reviews.
- Could have been higher
- Weather
- Cancellations
- Insurance refusal to cover
43Reason Given At Start of Visit for Seeing
Pharmacist (N18)
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45Chart Reviews
- Chart reviews were done on 9 patients.
- Chart reviews were requested by clinic staff if
they were concerned about potential medication
related issues.
46Chart Review Process
- Complete review of relevant medication related
material. - Often resulted in discussion with staff that
requested review. - Review and recommendations documented in the
chart for assessment team review.
47Chart Review vs. In-Person
- In-person visits result in significantly higher
issue identification.
48Chart Paper Patient Review
- Chart Paper Patient Review ( 9 patients)
- 32 issues/recommendations
- Average per patient 3.22
- Range 2 to 5
- Potentially Significant Issues 13
- Average per patient 1.44
- Insignificant per patient 1.78
- Range 0 to 2
- Potential Issues Involving Memory 14
- Average per patient 1.56
- Average per patient sig 0.67
49In-Person
- In-person review ( 18 patients)
- 115 issues/recommendations
- Average per patient 6.39
- Range 1 to 10
- Potential Issues Involving Memory 33
- Average per patient involving memory 1.83
- Average per patient significant/memory 1.28
- Potentially Significant Issues 50
- Average per patient 2.78
- Range 0 to 6
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51Issues From In-Person
52Issues From In-Person
53Issues From Chart Review
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59Examples Significant Potential Adverse Drug
Reactions
- Amitriptyline for fibromyalgia
- c/o dry mouth, constipation, dizziness upon
arising. Dizziness significantly interfering with
the quality of her life. Patient states she
becomes dizzy to the point of almost blacking out
at least 5 to 10 times upon standing up while at
church. - Patient states his blood pressure control is not
good. - Takes Effexor for depression
- Effexor may be associated with increased blood
pressure especially at higher doses. Using
337.5mg daily.
60Compliance
- Caregiver
- Caregiver presented appearing sedated, slow to
find words, slurred speech, and was slow to
respond. - Indicated she took four Vicodin shortly before
driving her husband to the clinic. - Stated she had extreme anxiety during the night,
taking up to three Klonopin at one time which
differs from her prescription of one tablet 3 to
4 x daily. - Of note, she was taking 18.25 mg of Ambien and
trazadone 200mg every night
61Compliance
- Patient lives alone and sets up her own
medications. Stated she has no problems setting
up her meds. Indicated a little trouble
remembering taking her vitamins. - Has a form she checks off when she sets up her
meds. After going to get a glass of water to take
her meds. Cannot always remember if the check
means she took med. - Orders for Tylenol with Codeine No. 3 Three tabs
4 X day and Vicodin 5/500 one or two tabs every 4
to 6 hours as needed. States she NEVER takes more
than the maximum amount allowed of either pain
med. - Discussion indicated she was likely using both T3
and Vicodin at or near their maximum daily doses.
This could have contributed to her memory
impairment plus puts her at risk of excessive
acetaminophen intake. Her T-3 alone put her at
the daily acetaminophen maximum of 4000mg daily. - Taking her Actonel with food and other
medications at times. Actonel must be taken on an
empty stomach first thing in the morning with
nothing but plain water before, with, or for ½
hour afterward.
62Potential Indication w/o Treatment
- Historical information in patients chart showed
a past diagnosis of B-12 deficiency. No B-12 was
noted on her medication list or evidence of a
B-12 level. - B-12 deficiency can cause memory loss.
- During our visit, she stated she had been on
Vitamin B-12 in the past. She did not know why
she wasnt receiving it now and had not had any
for many years. - Recommendation made to check B-12 level and
consider B-12 treatment, if indicated.
63Compliance / Dose
- Reason for requesting to see pharmacist
- Why was there a recall for isosorbide
mononitrate? - More to it than the initial questionhis real
question and reason was how long do I have to be
off isosorbide mononitrate before I can take
Viagra? - He had been reducing as isosorbide mononitrate
dose without his physicians knowledge.
64Potentially Significant Drug Interaction
- Patient taking gemfibrozil and verapamil with
simvastatin 80mg daily. - Recommended maximum daily simvastatin doses when
on - Verapamil is 20mg daily
- Gemfibrozil is 10mg daily
- Lower simvastatin dose is recommended due to
significantly increased risk of myopathy and
rhabdomyolysis ( condition where muscle cells
break down that can lead to muscle breakdown and
kidney failure)
65Lessons Learned
- Pharmacist MTM and educational services are
beneficial. - Potentially significant medication related issues
are common. - In-Person reviews yield more potential and
significant issues than chart reviews. - Caregivers and patients want complete medication
regimen reviews covering all medications and
aspects of medication use.
66Lessons Learned
- Caregivers and patients have many medication
related questions/issues they want to discuss. - Reimbursement for pharmacist MTM services is a
challenging issue. - Scheduling flexibility is necessary for both the
clinic and pharmacists. - Documentation time is significant.
67What Would We Do Differently?
- The process in setting up MTM services worked
well and no significant changes would be made. - Contacting insurance companies prior to providing
MTM services to see if they will cover MTM via
the clinic. - Consider expanding educational opportunities.
- Consider outcomes follow-up
68Sustainability
- We hope to increase the number of patients seen
at the clinic. - Sustainability is dependent on insurance
coverage, private reimbursement or alternative
funding sources. - The as needed model allows for pharmacist
availability without significant ongoing fixed
costs to the clinic. - Medicare D MTM insurance coverage is increasing.