Medication Management: A New Standard for Care Management Programs
Sandy AtkinsProject Director
Mira TrufasiuProject Manager
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
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
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.
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
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, 2006–2010, Hartford Foundation► Taking meds management statewide first then
nationwide in care management!
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
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 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 panel’s criteria
► 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
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.
Intervention – From Alerts to Action
.
An Alert is Generated
Care Manager (CM) confirms
med is currently used by client
CM emails alert to Pharmacist
Pharmacist creates recommendation
letter for MD & documents in
MSSPCare
Recommendations & med lists are
sent to MD
Pharmacist tracks status of
recommendations
MD response goes to Pharmacist. CMs
document updated med list and CM files in chart.
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 client’s MD(s) to request re-evaluation.
Occasionally identified other medication-related problems – outside of protocols.
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%
Race/Ethnicity by Site (N=615)
Evidence of Effectiveness 615 clients in 3 Medicaid waiver sites were screened 49% (N=299) 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% (N=118) of recommended changes were implemented.
Potential Medication Problems by Type
49% of clients had at least one potential medication problem (N=299)
► 24.2% w/ therapeutic duplication (N= 149)
► 14.3% w/ inappropriate psychotropic medications (N=88)
► 14.1% w/ cardiac problems (N=87) ► 12.8% w/ inappropriate NSAIDs
(N=79)
# of potential problems increases with # of medications taken
*p<.05, **p<.01, ***p<.001
0%
20%
40%
60%
80%
1-3 4-6 7-9 10-11 12+
# of Medications
AllProblems***
2+Problems***
TherapeuticDuplication***
Psychotropicw/ Falls*
Improvement after intervention
Medication Problems and Change Rates at 3-Month Follow-Up
Medication Problem
MSSP Sample Screened (N=615)
Medication Change (N=162)
N % Prevalence 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:
~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
Overall + responses to intervention & translation
Key differences
► Nurse / Social Worker perspectives
► Experience with EBP implementation
► Location of care managers
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”
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”
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
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
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
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
Medication Management Tools
Tracking and recording medication alerts in an automated system
Medication intervention protocols Health assessment Vital signs Progress notes
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
Next steps for the project: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.
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 ?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
Who can participate?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
Next Steps: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, [email protected]
► Sandy Atkins, Project Director - 818.837.3775 x111, [email protected]
Acknowledgements
Collaborators
Partners in Care FoundationDennee Frey, PharmD
June Simmons, LCSW
Mira Trufasiu, MSG
Sandy Atkins, MPA
Jennifer Wieckowski, MSG
Susan Enguidanos, PhD
Huntington Hospital Senior Care NetworkNeena Bixby, LCSW
Eileen Koons, MSW
Lois Zagha, MA
Pat Trollman, LCSW
USC Andrus Gerontology CenterGretchen 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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