Improving Medication Management in ALFs: A Pharmacist’s ... · 10/16/2008 · Rhoads M, Thai...

ImprovingMedicationManagementinALFs:APharmacist’sPerspective

NicoleBrandt,PharmD

MedicationManagementinALFs

• MedicationmanagementisonepotentialIADLthataresidentmayreceiveassistancewith– Approximately85%ofresidentsgethelpwiththeirmedications

Losben NL. Medication management programs: A safe investment. Assisted Living Consult. January/February 2005.23-25.

Assisted Living Federation of America (ALFA). 2006 Overview of Assisted Living Facts & Trends. Alexandria, VA:ALFA;2006

• SinceALF’sareregulatedbythestateratherthanfederalgovernment,variationsofregulationsexist

• In2003,theAssistedLivingWorkgroupcreatedalistofrecommendedpoliciesconcerningmedicationmanagementinALF’s



RecommendedPoliciesforMedicationManagement

• Medicationorders,includingtelephoneorders

• Pharmacyservices

• Medicationpackaging

• Medicationorderingandreceipt

• Medicationstorage

• Losben NL. Medication management programs: A safe investment. Assisted Living Consult. January/February 2005.23-25.

• Assisted Living Federation of America (ALFA). 2006 Overview of Assisted Living Facts & Trends. Alexandria, VA:ALFA;2006

RecommendedPolicies,cont’d.

• Disposalofmedicationsandmedication‐relatedequipment

• Medicationself–administrationbytheresident

• Medicationreminders

• Medicationadministration




• Medicationadministration–specificprocedures

• Documentationofmedicationadministration

• Medicationerrordetectionandreporting






• Qualityimprovementsystem,includingmedicationpreventionandreduction

• Medicationmonitoringandreportingofadversedrugeffectstotheprescriber

LosbenNL.Medicationmanagementprograms:Asafeinvestment.AssistedLivingConsult.January/February2005.23‐25.

AssistedLivingFederationofAmerica(ALFA).2006OverviewofAssistedLivingFacts&Trends.Alexandria,VA:ALFA;2006

Recommendedpolicies,cont’d.

• Reviewofmedication

• Storageandaccountabilityofcontrolleddrugs

• Training,qualificationsandsupervisionofstaffinvolvedinmedicationmanagement

• Losben NL. Medication management programs: A safe investment. Assisted Living Consult. January/February 2005.23-25.


ImportanceofMedicationManagementinAssistedLiving

• Thepurposeoftherecommendedpoliciesweretohelpfacilitiescreateamedicationmanagementservicethatwouldworkeffectivelyandprovidecorrectmedicationtotheresidents.

AssistedLivingWorkgroupReporttotheU.S.SenateSpecialCommitteeonAging.TopicGroupRecommendationsAdoptedbyTwo‐ThirdsMajorityoftheALW.April2003

• Thestaffofferingadministrationorassistancewouldbeknowledgeableaboutthemedication

• Residentsthatneededhelpwiththeirmedicationwouldgetthecorrectdrugs

• Areviewofthemedicationswoulddecreasepotentiallyharmfulinteractionsoreffectsaswellaslowercosts

• AssistedLivingWorkgroupReporttotheU.S.SenateSpecialCommitteeonAging.TopicGroupRecommendationsAdoptedbyTwo‐ThirdsMajorityoftheALW.April2003

OngoingMedicationManagementChallenges….

• In2008,5yearslater,aMedicationManagementSymposiumnotedthat:

• Balancingconsumersafetyandautonomywithselfadministrationisongoing

• LackoftrainedhealthcareprofessionalsspecializingingeriatricscaringforresidentsinALFs

Report from an Expert Symposium on Medication Management in Assisted Living

accessed http://www.assistedlivingconsult.com/issues/04-04/alc78-White%20Paper-728b.pdf on October 16, 2008.

Challenges,cont’d.

• Lackofuniformityinstateregulationsregardingmedicationmanagement,administrationandassistance

• Littletrainingisofferedtounlicensedassistivepersonnelwhoadministermedications

ReportfromanExpertSymposiumonMedicationManagementinAssistedLiving

accessedhttp://www.assistedlivingconsult.com/issues/04‐04/alc78‐White%20Paper‐728b.pdfonOctober16,2008.

WhathaveweseeninALFs?

IncreasingNumbersofMedicationsUsed

• Astudyfrom2001focusingon608residentslivingin109assistedlivingfacilitiesfound:

• Residentsreceivedanaverageof6.2(+/‐3.4)regularlyorderedmedications

Armstrong EP, Rhoads M, Meiling F. Medication usage patterns in assisted living facilities. The Consultant Pharmacist. 2001;16(1).

• Morethanhalf(58.4%)ofthesemedicationsconsistedofcardiovascular,CNSornutritionalmedications

• Thehighnumberofroutineprescriptionscouldleadtopotentialdrugrelatedproblemsthatcouldbeavoidedifaconsultantpharmacistperformedamedicationreview

• Armstrong EP, Rhoads M, Meiling F. Medication usage patterns in assisted living facilities. The Consultant Pharmacist.2001;16(1).

InappropriateMedicationUse

• Astudyfrom2003focusingon456residentsfrom124differentassistedlivingfacilitiesfound:

• 144residentshadoneormorepossibleinappropriateroutineorasneededprescriptionsaccordingtoBeer’scriteriaforatotalof204inappropriateorders

Rhoads M, Thai Amy. Physician acceptance rate of pharmacist recommendations to reduce use of potentially inappropriate medications in the assistedliving setting. The Consultant Pharmacist. 2003;18(3).

• 64ordersweredeterminedtohavearatingofhighseverity

• Oxybutyninandpropoxyphenewerethetwomostfrequentlyprescribeddrugsthatcouldbeinappropriate

• Consultantpharmacyservicesresultedin16.7%ofthepotentiallyinappropriateordersbeingstoppedand2.5%oftheordersreceivingdosechanges(lower)

• Rhoads M, Thai Amy. Physician acceptance rate of pharmacist recommendations to reduce use of potentially inappropriatemedications in the assisted living setting. The Consultant Pharmacist. 2003;18(3).

HowdoesthisimpacttheresidentsinALFs?

• Amongtheelderly,28%ofhospitalizationsareduetomedicationadverseeventsormedicationnon‐adherence

• Oneoutofeveryfournursinghomeadmissionsisattributedtomedicationmis‐management

• Adversedrugeventshavebeenreportedasthe4thleadingcauseofdeathamongseniorsandareestimatedtocost$177.4billiondollarseachyear

• Medicationmisuseisparticularlyhighfollowinghospitalization,andevenmoresowhenmultiplechangesaremadetoolderpatient’sregimen

• Eachyeartherearemorethan180,000potentiallyfatalorfataladversedrugeventsamongMedicarerecipients.– 50%oftheseadverseeventscouldhavebeenprevented

• Medication‐relatedproblemsduetoinappropriateprescribinghasbeendeemedoneofthemostimportantquality‐of‐careissuesforelderlypatients.Forovertwodecades.

Citationsforpreviousthreeslides

• NanadaC,FanaleJE,KronholmP.Theroleofmedicationcomplianceandadversedrugreactionsinhospitalizationsoftheelderly.ArchInternMed1990;150:841‐5.

• BergJS,et.al.Medicationcompliance:ahealthcareproblem.AnnPharmacother1993;27(suppl):S5‐S19.

• LazarouJet.al.Incidenceofadversedrugreactionsinhospitalizedpatients.JAMA1993;279:1200‐5.

• CurtisLH,OstbyeT,SenderskyV,et.al.InappropriateprescribingforelderlyAmericansinalargeoutpatientpopulation.ArchIntMed2004;164(15):1621‐5.

• ForsterAJ,et.al.Theincidenceandseverityofadverseeventsaffectingpatientsafterdischargefromthehospital.AnnInternMed2003;138:161‐7;BeersMH,et.al.Influenceofhospitalizationondrugtherapyintheelderly.JAmGeriatrSoc1989;37:679‐83.

• GurwitzJH,FieldTS,HarroldLR,et.al.Incidenceandpreventabilityofadversedrugeventsamongolderpersonsintheambulatorysetting.JAMA2003;289:1107‐16

• FinkA.et.al.Assuringqualityofhealthcareforolderpersons.JAMA1987;258:1905‐8.

PotentialRisksofMedicationsandBenefitsofaPharmacist

1)MedicationRelatedProblems• Oneoutofevery5emergencyroomvisitsare

thoughttobeduetomedicationrelatedproblems

• Theidentificationofmedicationrelatedproblemsbyaconsultantpharmacistmaysavethehealthycaresystemaround$2,250dollarsayearperresidentbypreventingunnecessarytripstotheER

Clark TR. Prevention of medication-related problems in assisted living: role of the consultant pharmacist. ASCP Issue Paper. 2003.

2)MedicationErrors• Correctimproperdosing,administrationandorders

3)HigherMedicationExpenditures:• Reducetheresident’smedicationcostsbychangingtogenerics,lessexpensivesimilardrugs,orstoppingmedicationsthatarenotnecessary

• Clark TR. Prevention of medication-related problems in assisted living: role of the consultant pharmacist. ASCP Issue Paper.2003.

WhataresomeofthethingsthataPharmacyandPharmacistcandoto

helpyou?

1.PerformaMedicationRegimenReview(MRR)

• WhatisMRR?– “Thoroughevaluationofthemedicationregimenofaresident,withthegoalofpromotingpositiveoutcomesandminimizingadverseconsequencesassociatedwithmedications;Thereviewincludespreventing,identifying,reporting,andresolvingmedication‐relatedproblems(MRPs),medicationerrors,orotherirregularitiesandcollaboratingwithothersmembersoftheinterdisciplinaryteam.”

Centers for Medicare and Medicaid Services. State Operations Manutal. Appendix PP: Guidance to Surveyors for Long Term care facilities Rev. 26 Accessed at www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdfwww.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf. on October 16, 2008.

2.ProvideOngoingEducationtoDirectCareStaff,Residentsand/orthe

Family• Medicationmanagementisbasedinthecareprocessandincludes:– Recognitionoridentificationoftheproblem/need

– Assessment

– Diagnosis/causeidentification

– Management/treatment

– Monitoring

– Revisinginterventions• CentersforMedicareandMedicaidServices.StateOperationsManutal.AppendixPP:GuidancetoSurveyorsforLongTermcare

facilitiesRev.26,Accessedatwww.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdfwww.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf.onOctober16,2008.

3.AssistwithAssessingResident’sabilitytoSelfAdministerMedications

Variousscreeningandassessmenttoolstoevlauatearesident’sabilitytoselfmedicate.

e.g.,MediCog:evaluatestheabilitytosetupapillbox

TwoPartScreen

Mini‐Cog:detectsclinicallysignificantcognitiveimpairment

MedicationTransferScreen(MTS):evaluatesskillsindecipheringprescriptionsandabilitytosequenceandlocate

CentersforMedicareandMedicaidServices.StateOperationsManutal.AppendixPP:GuidancetoSurveyorsforLongTermcarefacilitiesRev.26• Accessedatwww.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdfwww.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf.onOctober16,2008.

3.Assessing…con’td.

• Fivetotenminutestoadminister

• RequiresapencilandapreprintedMTSform.

• CentersforMedicareandMedicaidServices.StateOperationsManutal.AppendixPP:GuidancetoSurveyorsforLongTermcarefacilitiesRev.26

• Accessedatwww.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdfwww.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf.onOctober16,2008.

4.AssistwithPharmaceuticalServices

PharmaceuticalServices”refersto:• Theprocess(includingdocumentation,asapplicable)ofreceivingandinterpretingprescriber’sorders;acquiring,receiving,storing,controlling,reconciling,compounding(e.g.,intravenousantibiotics),dispensing,packaging,labeling,distributing,administering,monitoringresponsesto,usingand/ordisposingofallmedications,biologicals,chemicals(e.g.,povidoneiodine,hydrogenperoxide);

• Theprovisionofmedication‐relatedinformationtohealthcareprofessionalsandresidents;

• Theprocessofidentifying,evaluatingandaddressingmedication‐relatedissuesincludingthepreventionandreportingofmedicationerrors;and

• Theprovision,monitoringand/ortheuseofmedication‐relateddevices.

Whatcanbedonetoassuremedicationgetsmanagedappropriately,safelyand

accurately?

Mythoughts…

• AdvocateforclearerpoliciesandregulationsinALFs

• Hireaconsultantpharmacisttoperformmedicationmanagementreviews

• Ensureongoingevaluationsofmedicationadministration

• Remembertorespecttherightsoftheresident

Improving Medication Management in ALFs: A Pharmacist’s ... · 10/16/2008 · Rhoads M, Thai...

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