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Medication Management: A New Standard for Care Management Programs

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Title: Medication Management: A New Standard for Care Management Programs


1
Medication Management A New Standard for Care
Management Programs
Sandy Atkins Project Director Mira
Trufasiu Project Manager
2
Partners in Care Foundation
  • Los Angeles, CA
  • Changing the shape of health care
  • Collaboration Innovation Impact
  • Design, develop and pilot new programs that will
    serve as replicable models of care

3
The Importance of Evidence-based Programs
  • 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

4
Medication Management Project Purpose
  • 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 care-management services at home.
  • Improve client health and safety by managing
    medications
  • Evaluate client and program-level outcomes.

5
Why Use Care Managers?
  • Focused on maintaining health status, delaying
    institutionalization, and improving linkages with
    medical community resources
  • Already collecting medication and clinical
    information
  • Visit frail, low-income seniors in their homes
  • Established rapport with and care about their
    clients
  • Linguistically and culturally competent staff
  • Knowledgeable of available resources

6
Evolution of Medication Management Program
  • 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, 20062010, Hartford Foundation
  • Taking meds management statewide first then
    nationwide in care management!

7
Medication Management Project Rationale
  • Patient Safety - Medication errors are
  • Serious At least 1.5 million preventable adverse
    drug events (ADEs) each year 7,000 deaths per
    year due to ADEs. 1,3
  • Frequent Up to 48 of community dwelling older
    adults have medication-related problems 2
  • Costly Drug-related morbidity and mortality for
    seniors exceeds 170 billion (includes hospital
    and long-term care admissions) 2
  • 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
  • IOM (1999) To err is human Building a safer
    health system. Kohn, L., Corrigan, J., Donaldson,
    M. (Eds.) National Academy Press, Washington D.C.
  • 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 2862823-9.
  • IOM (2006) Preventing Medication Errors.

8
Evidence-Based Origins
  • Hartford/Vanderbilt Randomized Controlled Trial
    in Medicare home health patients aged 65.
  • 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
    panels criteria
  • Medication use improved in 50 of intervention
    patients,
  • compared to 38 of controls (p.05) when a
    pharmacist
  • helped homecare staff

9
Your condition has no symptoms or health risks,
but there is a great new pill for it.
10
Medication Risk Assessment Screening
  • RN care managers collect clients medications
    lists and clinical indicators
  • Vital signs, falls, dizziness, uncharacteristic
    confusion
  • Med lists are screened by a consultant
    pharmacist. Focus on the four most common
    medication errors
  • Unnecessary therapeutic duplication
  • Cardiovascular medication problems related to
    dizziness, continued high blood pressure, low
    blood pressure, or low pulse
  • Falls, dizziness, or confusion possibly caused by
    inappropriate psychotropic drugs
  • Inappropriate use of non-steroidal
    anti-inflammatory drugs (NSAIDs) in those with
    risk factors for peptic ulcer.

11
Intervention From Alerts to Action
12
Role of the pharmacist
  • 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 clients MD(s) to request
    re-evaluation.
  • Occasionally identified other medication-related
    problems outside of protocols.

13
Population Characteristics
  • 615 clients screened at 3 Medicaid waiver sites
    in LA County
  • 65
  • certifiable for skilled nursing facility
    placement
  • Dually eligible (Medicare Medicaid)
  • Average age 81 (65-108)
  • Female 80
  • Hospitalization, SNF, or ER in last year? 38
    yes
  • Falls in last 3 Months 22
  • Dizziness 27
  • Confusion 31
  • Lived alone 21
  • Mean of medications 8.76
  • 12 medications 22

14
Race/Ethnicity by Site (N615)
15
Evidence of Effectiveness
  • 615 clients in 3 Medicaid waiver sites were
    screened
  • 49 (N299) had potential medication problems.
  • Record review and consultation with the client
    led the pharmacist to recommend
  • Continue the medications - necessary for
    pain/symptom control
  • Collect more information - vital signs and other
    clinical indicators
  • 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 (N118) of recommended changes were
    implemented.

16
Potential Medication Problems by Type
  • 49 of clients had at least one potential
    medication problem (N299)
  • 24.2 w/ therapeutic duplication (N 149)
  • 14.3 w/ inappropriate psychotropic medications
    (N88)
  • 14.1 w/ cardiac problems (N87)
  • 12.8 w/ inappropriate NSAIDs (N79)

17
of potential problems increases with of
medications taken
p 18
Improvement after intervention
19
Results
  • 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

20
Waiver Staff Perspectives on Project
  • Overall responses to intervention translation
  • Key differences
  • Nurse / Social Worker perspectives
  • Experience with EBP implementation
  • Location of care managers

21
CM Feedback on Project Benefits
  • 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

22
CM Feedback on Project Challenges
  • 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

23
Conclusions
  • High prevalence of potential problems for those
    at risk for institutionalization suggests a need
    for more systematic medication management in
    community-based 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

24
Lessons Learned from Study
  • Need for a computerized medication risk
    assessment and alert system
  • Hybrid nature of MSSP presented challenges
  • MD Communication
  • Scope of Practice
  • Clinical issues e.g. cardiac assessment
  • Agency readiness is essential for success

25
Indicators of Agency Readiness
  • There must be a felt need
  • A sense of the importance and urgency of the
    problem
  • There must be a champion
  • Pull others along, learn systems, mentor others,
    serve as an example, and cheerlead when there are
    successes.
  • There must be underlying stability
  • Resources viewed as adequate
  • Staff turnover minimal
  • Recovery time since last big change

26
Implementation Experience
  • Start small
  • Champion small team
  • New enrollees only
  • Changing care management practice.
  • Ongoing training
  • Staff mentor each other
  • Staff choice in design options
  • Leadership emphasizes the importance of
    follow-through
  • Clear policies and protocols
  • Rewards, challenges, contests
  • Help with routine data entry
  • Use community pharmacy resources creatively.
  • 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.
  • Usually FAX
  • Pharmacist, nurse, or care manager

27
Medication Management Tools
  • Tracking and recording medication alerts in an
    automated system
  • Medication intervention protocols
  • Health assessment
  • Vital signs
  • Progress notes

28
Sustaining the Program
  • Provide ongoing support and education for staff
  • Train new staff members in orientation
  • Arrange for pharmacist consultant
  • Identify best practices and problems.
  • Provide feedback to staff, funders, and community
    partners
  • Identify and recognize program champions
  • Provide updates and an opportunity to share ideas
    and problem-solve

29
Next steps for the project
  • More widespread application of the model program
  • 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
  • The National Institutes of Health has chosen RTZ
    to develop an information system for community
    long-term care across waiver programs.

30
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.

31
What are the benefits ?
  • 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

32
Who can participate?
  • At this time there are two absolute prerequisites
    to participate as demonstration project site
  • Must be a Medicaid waiver program for elders
  • Care managers must be using a computerized client
    assessment system
  • Sites must also
  • Collect medication and clinical information
  • Arrange for a pharmacist or medication consultant

33
Next Steps
  • For more information www.HomeMeds.org
  • 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
  • Mira Trufasiu, Project Manager - 818.837.3775
    x112, mtrufasiu_at_picf.org
  • Sandy Atkins, Project Director - 818.837.3775
    x111, satkins_at_picf.org

34
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
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