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