Medication Management The ACH Connection

1
Medication ManagementThe ACH Connection
2
Objectives

• Recognize impact of medication on ACH rates
• Identify QMAP best practices and supporting
  resources to promote improvement in oral
  medication management

3
Medication Management

• A strategy utilizing specific interventions to
  assess and monitor the patient/caregiver ability
  and willingness to accurately and safely maintain
  the physician-ordered medication regimen as a
  means of reducing hospitalizations
• 2006 Briggs National Quality Improvement/Hospital
  ization Reduction Study

4
Medication Management

• Medication-related complications play a
  significant role in the hospitalization of older
  adults and are a contributing factor in accidents
  and illnesses that lead to hospitalization.
• 2006 Briggs National Quality Improvement/Hospital
  ization Reduction Study

5
Medication Management

• Significance confirmed by
• JCAHO Safety Goals
• Care Transitions Program
• Briggs National Quality Improvement
  Hospitalization Risk Study
• Medicare Modernization Act Provisions

6
Improving Management of Oral Medications

• Georgia Statewide Measure for Improvement
• Home Health Compare

March 2005-February 2006
7
Georgia Progress to date
8
Q-MAP

• Quality Medication Administration Project

9
What is Q-MAP?

• Collaborative quality initiative to improve
  management of oral medications in home setting
• Piloted by 22 PA agencies in 2005
• Currently national initiative

10
Objectives of Q-MAP

• Identify Best Practices to support evidence base
  for improving medication management
• Implement Best Practice Tools Supporting
  Resources
• Support reduction in avoidable hospitalizations

11
Q-MAP Development

• Technical Expert Panel
• Piloted in Pennsylvania
• Creation of Change Package
• Best Practice Tools
• Supporting Resources

12
Q-MAP Success

• 18 of the 22 participating agencies achieved
  their target rate in 6 months
• Q-MAP National Collaborative 2006

13
Section I Best Practice ToolsSection
IISupporting Resources
Q-MAP Change Package
14
How will your agency use the Change Package???

• Modify and adapt to unique needs of your agency
• Change Package is not set in stone
• Select individual tools and resources
• Do not need to use everything

15
Best Practice Tools

• Medication Assessment Protocol
• Medication Non-Adherence Staff Education Tool
• Managing Your Medications
• Medication Teaching Strategies
• Medication Simplification Protocol
• Beers Criteria
• Medication Compliance Aids
• Oral Meds Care Planning Tool

16
Best Practice Tool
17
Step 1
Clinician Observation Assessment
Instruction

• Observe patient prepare
• Is process organized?
• Identify compliance aids
• If assistance provided, is it necessary?

• Ask patient to demonstrate how they take their
  meds
• Ask if anyone helps them prepare or select
  appropriate meds

18
Step 2
Clinician Observation Assessment
Instruction

• Once med supplies assembled or accessed
• Ask patient to describe how they would proceed
  with taking their meds
• What would you do first?
• Second?
• Etc.

• Is the process appropriate as described?
• Correct dosage, time and frequency?
• Check patients response against directions for
  specific meds.

19
Step 3
Clinician Observation Assessment
Instruction

• If ability to sequence multi-step med
  administration is not evident
• Ask patient to demonstrate a multi-step med
  administration task
• e.g. Please show me how you would open your med
  bottles and take your med.

• Does patient demonstrate ability to complete all
  steps appropriately?
• Selects appropriate bottles
• Opens each and selects correct does prior to
  closing
• Takes med as directed
• Closes lid(s) and returns to storage

20
Step 4
Clinician Observation Assessment
Instruction

• Check adherence
• As part of the comprehensive assessment
• AND on ongoing basis

• Determine compliance by reviewing calendar,
  diary, list, pillbox, etc.
• Select one med with known start date and count
  pills to verify compliance
• Does patient have any established daily routines
  which are (or could be) tied-in to med
  administration

21
Adapting to your Agency

• Problem Statement
• Clinicians are not consistently assessing
  patients ability to safely prepare and take
  their oral medications.
• Best Practice
• At SOC/ROC, the admitting clinician will refer to
  the Medication Assessment Protocol when reviewing
  the patients medication list and assessing
  adherence.

22
Best Practice ToolMedication Non-Adherence(Staff
Education Tool)
23
Factors to Consider/Assess

• Knowledge deficit
• Literacy
• Financial concerns
• Fear of addiction or dependency
• Over-medicating or diversion

• Health beliefs/expectation
• Memory deficits
• Functional deficits
• Disorganization (in space or in time)

24
Knowledge

• Is there evidence which indicates that the
  patient or caregiver does not understand
• The purpose
• Dosing instructions
• Timing of doses or
• How long the medication should be taken?

25
Literacy

• Is there evidence which indicates that the
  patient or caregiver is unable to read either the
  medication labels or any additional text
  instructions provided?

26
Financial concerns

• Is there evidence to suggest that the patient
  is either limiting medication use to conserve
  supply, or foregoing either doses or refills due
  to financial concerns?

27
Fear of addiction or dependency

• Is there evidence to suggest that the patient
  is concerned about becoming addicted to or
  dependent upon medications?

28
Overmedicating or Diversion

• Is there evidence to indicate that the
  patient is taking too much medication or that
  medication may be diverted to others?

29
Health Beliefs/Expectations

• Is there evidence to indicate that taking the
  medication conflicts with general beliefs or
  expectations that the patient has about health or
  wellness?

30
Memory

• Is there evidence to indicate that the
  patient forgets to take medication, or forgets
  that medications have already been taken?

31
Function

• Is there evidence that the patient has
  functional deficits that affect medication
  management (e.g. vision, grasp and dexterity,
  swallowing, mobility deficits)?

32
Organization

• Is there evidence suggesting that the patient
  has difficulty establishing or sustaining
  organization (of the environment and/or routine)
  to support the medication regime?

33
Adapting to your Agency

• Problem Statement
• If poor medication non-adherence is identified,
  there is not a thorough evaluation of underlying
  causes nor follow-up clinical interventions.
• Best Practice
• At every skilled visit, the clinician will
  evaluate patients medication compliance with the
  Medication Non-Adherence Tool.
• When compliance/adherence issues are identified,
  underlying causes will be explored and
  appropriate referrals will be made.

34
Best Practice Tool
MANAGING YOUR MEDICINES
35
Managing Your Medicines

• I have new medicines.
• I have changed medicines.
• I dont understand the instructions related to my
  medicines.
• I am not sure how my medicines help my condition.
• I dont think that my medicines help me.

• Knowledge OR Organization
• Knowledge OR Organization
• Knowledge
• Knowledge OR Health Beliefs
• Health Beliefs

36
Managing Your Medicines

• I am concerned about side effects.
• I dont always remember to take my medicines at
  the right time.
• I have trouble reading or seeing small print
  instructions on medicine bottles.
• I have trouble holding the small pills or opening
  the packaging on the medicine bottles.
• I have trouble paying for my medicines

• Fear of addiction OR Health Beliefs
• Memory OR Organization
• Functional abilities (vision) OR possibly
  Literacy
• Functional abilities (grasp/dexterity/sensation)
• Financial concerns

37
Adapting to your Agency

• Options
• Ask that patient complete the tool during the
  course of a visit or between visits
• Use with your rehab only patients
• Include in your SOC packet to be used at the
  discretion of the admitting clinician

38
Best Practice ToolMed Teaching Strategies
39
Med Teaching Strategies Assess

• Explore reasons patient might not be motivated
• Assess how the patient best learns
• Work with the patient and family to help them
  identify and state specific patient focused key
  problems
• Develop medication teaching goals for home care
  based upon patient focused key problems with the
  patient and family

40
Med Teaching Strategies

• Teach
• Ensure an environment conducive to patient
  education
• Use appropriate teaching strategies and tools

41
Med Teaching Strategies Evaluate

• Observe and compare medication administration
  practices in relation to knowledge
• Ask specific patient-focused, open-ended
  questions, as appropriate, in relation to what
  was previously taught

42
Med Teaching Strategies Evaluate

• Does the patient verbalize at least basic
  knowledge?
• Does the patient require more teaching?
• Is it a more realistic goal that s/he can access
  information as needed from medication teaching
  sheets?
• Provide positive reinforcement
• Summarize what your patient has learned

43
Adapting to your Agency

• Problem Statement
• A consistent and organized approach in assessing,
  teaching, and evaluating medication management is
  not always used.
• Best Practice Statement
• For all patients, the assessing clinician will
  use the Med Teaching Strategies Protocol.

44
Best Practice ToolMedication Simplification
Protocol
45
Best Practice ToolMedication Simplification
Protocol

• 1) Remove unnecessary or expired drugs to prevent
  confusion.
• 2) Encourage use of a single pharmacy
• 3) Consider non-pharmacologic alternatives
• 4) Coordinate administration times with
  established sleep and activity patterns/routines.
• The next steps require you to involve the
  prescribing MD
• 5) Decrease administration frequency, using
  sustained-release or long acting products
• 6) Reduce multiple medications to treat a single
  condition, unless combination therapy is
  intentional.
• 7) Discontinue/substitute cautionary medications
  known to be problematic for geriatric patients
  (e.g., Beers
• Criteria).

46
Best Practice Tool Beers Criteria
47
Adapting to your Agency

• Problem Statement
• There is no process for clinicians to address
  polypharmacy
• Best Practice Statement
• For all patients taking more than 8 medications,
  the assessing nurse or therapist will implement
  the Medication Simplification Protocol.

48
Best Practice ToolMedication Compliance
AidsSelection Criteria
49
Purpose of Compliance Aids

• To move the patient toward independent medication
  management

50
Types of Compliance Aids

• Compliance Packaging
• Medication alarms
• Recorded messages
• Telephone reminders
• Automated dispensers

• Medication List (text)
• Medication Schedule (text, illustration, and
  time)
• Pill box

51
Medication List

• May be written by patient or caregiver
• Little or no cost
• Should include all elements of medication
  administration, name, date, time, dose, route,
  special instructions, etc....

52
Skills Required to Use Med List

• Adequate vision
• Read simple words and phrases
• Recognize and monitor time
• Match written word to time, drug, and task

53
Medication Schedule

• Medication list with illustrated drug and time
• May be more difficult for patient or caregiver to
  design or maintain after discharge
• Low cost

54
Skills Required for Medication Schedule

• Adequate vision
• Able to read, OR
• Able to match word or picture to actual
  medication
• Able to match written word or picture to number
  of pills, time of day, and task
• Able to monitor time

55
Pill Box

• Basic models are readily available
• Little or no cost to more expensive electronic
  versions
• Organizes medication by day
• May provide one or multiple boxes for each day
• Allows for multiple day set up by caregivers

56
Skills Required for Pill Box Use

• Adequate vision
• Fine motor skills to open lids
• Ability to read OR
• Match word or picture on box to day of week, time
  of day, etc.
• Ability to recognize and monitor time of day

57
Compliance Packaging

• Is often more expensive than routine packaging
• May be difficult for patients with tremors,
  strength deficits, or motor difficulties to open
  to access medications
• Not all medications are readily available in this
  format

58
Skills Required for Compliance Packaging Use

• Adequate fine motor ability to open packaging
• Ability to read OR
• Ability to match word or picture on pack to
  number of pills and time of day
• Ability to recognize and monitor day and time

59
Medication Alarms

• Variations in type and number of alarms within
  the device
• Prices range from low to high cost
• Selection varies widely in different markets
• May be worn on the wrist or around the neck
• May be placed on furniture or carried from room
  to room

www.forgettingthepill.com
60
Skills Required for Medication Alarm Use

• Adequate hearing sensitivity and auditory
  processing OR
• Adequate vision and visual perception
• Ability to match alarm to drug and task
• Able to access and take drugs when reminded

61
Recorded Messages

• Simple to complex messaging devices
• Price ranges from moderate to expensive
• May not be easily found in some areas
• Requires caregiver to record understandable
  message and update as needed

www.epill.com
62
Skills Needed for Recorded Message Use

• Ability to initiate message playback system
• Adequate hearing and auditory comprehension to
  detect and understand auditory message (length
  and complexity within patients processing
  capacity)
• Able to match spoken word to task
• Able to access and take drug in response to
  message

63
Telephone Reminder

• May be live or pre-recorded
• No to little cost
• May be option with telehealth unit

64
Skills Required for Telephone Reminder Use

• Telephone access
• Ability to answer phone
• Adequate hearing and auditory comprehension to
  hear and understand the reminder message
• Able to match instructions to task
• Able to access and take drugs as instructed

65
Automated Dispensing

• Moderate to very expensive
• May not be locally available
• Range from simple to very complex units
• Set up and maintenance ranges from simple to
  complex
• Most require batteries
• Complex units may be intimidating
• to older patients

www.epill.com
66
Skills Required for Automated Dispenser Use

• Adequate hearing to recognize auditory alarm OR
• Adequate vision and access to recognize visual
  cue
• Ability to match alarm to task
• Able to access and take drugs in response to alarm

67
Adapting to your Agency

• Problem Statement
• Medication compliance aids are not being matched
  to patients skill level
• Best Practice Statement
• Clinician will match patient skills with
  appropriate compliance aid using the Medication
  Compliance Aid Selection Criteria.

68
Best PracticeToolOral MedicationsCare
Planning Tool
69
Outcome Interval Analysis

• Reviewing the OASIS item on which a quality
  measure is calculated in order to determine the
  specific clinical or functional changes which
  will need to be achieved in order for the quality
  measure to be impacted.

70
Outcome Interval Analysis

• M0780 Management of Oral
  Medications
• Patients ability to prepare
  and take all prescribed oral
  medications reliably and safely,
  including administration of the correct
  dosage at the appropriate times/intervals.
• 0 Able to independently take the correct
  oral
• medication(s) and proper dosage(s) at
  the correct
• times.
• 1 Able to take medication(s) at the correct
  times if
• (a) individual dosages are prepared in
  advance by
• another person OR
• (b) given daily reminders OR
• (c) someone develops a drug diary or
  chart.
• Unable to take medication unless administered
  by
• someone else.
• NA No oral medications prescribed.
• UK Unknown

71
For M0780 Outcome Interval 2 ? 1
Physiogical

• Barrier
• Pain results in need for meds to be administered
  by someone else

• Action for consideration
• Referral to RN/PT/OT
• -pain management interventions

72
For M0780 Outcome Interval 1 ? 0
Physical

• Barrier
• Dysphagia prevents safe ingestion of oral
  medications unless without assistance

• Action for consideration
• Referral to SLP
• Dysphagia therapy

73
Adapting to your Agency

• Options
• Staff education
• Case Conference
• Record review

74
Q-Map Change PackageSection II Supporting
Resources
75
Q-MAP Supporting Resources

• Q-MAP Related to Home Therapy

76
Q-MAP Supporting Resources

• Reminders for Personal Care Home/
• Assisted Living Patients

77
Q-MAP Supporting Resources

• Q-MAP related to Home Health Aides

78
Q-MAP Supporting Resources

• Q-MAP and Physicians
• Physician Letter
• Introducing Q-MAP
• Med simplification
• Beers Criteria letter
• Fax Statement
• Script for talking to MDs

79
Q-MAP Supporting Resources

• Q-MAP Clinicians
• Making it Personal
• New Hire Orientation

80
Q-MAP Supporting Resources

• Q-MAP Patients
• You and Your Medicines
• Case Conference/
• Care Planning Form

81
Reminder

• Change Package Section I Best Practice Tools
  may be adapted according to HHA identified
  problems (except Beers Criteria)
• Change Package Section II Supporting Resources
  - optional use by HHAs may be adapted

82
Additional Resource

• Six QMAP learning sessions--- 3 available as
  Webex on www.medqic.org
• Handout

83
QUESTIONS???
This material was prepared by Quality Insights of
Pennsylvania, the Medicare Quality Improvement
Organization Support Center for Home Health,
under contract with the Centers for Medicare
Medicaid Services (CMS), an agency of the U.S.
Department of Health and Human Services. The
contents presented do not necessarily reflect CMS
policy. Publication number 8SOW-PA-HHQ06.178.