Oral Medication Management Assessment

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Oral Medication ManagementAssessment
InterventionJuly 25, 2007
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• an independent, not-for-profit corporation
  committed to assessing andimproving the value of
  health care services through the use of
  innovative methods
• and technologies.

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Program Objectives

• Review the components of the management of oral
  medications quality measure NYS progress to
  date
• Discuss the importance of accurate patient
  assessment and application of interventions to
  improve oral medication management
• Review important considerations for agency
  organizational assessment for improvement in oral
  medication management
• Identify resources to support agency performance
  improvement efforts

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Historical Perspective Quality Measure Rates

• Launch of Home Health Compare (11/2003)
• National Average 35
• NYS Average 38
• 06/2007 Update of Home Health Compare
  (01/2006-12/2006)
• National Average 42
• NYS Average 44
• CMS 8th Scope of Work Goal (09/2006-08/2007)
  90
• Current 8 SOW Risk-adjusted Rate
  (04/2006-03/2007)
• National - 42
• NYS 37

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Strategies for Success

• How can we improve our patients ability to
  manage their oral medications over the course of
  the home care episode?
• Utilize agency clinical staff to identify
  clinical activities / actions that might improve
  ability to manage oral medications
• Assessment
• Clinical Interventions / Teaching

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OASIS Item M0780(Source OASIS Implementation
Manual Chapter 8 12/02
Prior Current ? ? 0 Able to independently take the correct oral medication(s) 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.
? ? 2 Unable to take medication unless administered by someone else.
? ? NA No oral medications prescribed.
? ? UK Unknown
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OASIS Item M0780 (Source OASIS Implementation
Manual Chapter 8 12/02)

• Patients ability to prepare and take all
  prescribed oral medications reliably and safely,
  including administration of the correct dosage at
  the appropriate times/intervals
• Excludes injectable IV medications
• Refers to ability, not compliance or willingness
• Preparing includes reading label, opening the
  container, selecting the correct dose orally
  ingesting at the prescribed time

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OASIS Item M0780(Source OASIS Implementation
Manual Chapter 8 12/02)

• Only medications whose route of administration is
  PO should be considered for this item
• Includes both prescribed and over the counter
  medications
• Medications given per gastrostomy (or other) tube
  are not administered PO, but are administered
  per tube

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Calculation of Outcome Rate

• OASIS data from SOC/ROC AND discharge/transfer
  during the specified 12-month time period
• Numerator all episodes that had the outcome
  (potential to improve)
• Denominator all eligible episodes
• Optimal status at SOC / ROC is excluded (NOT a
  0 for MO780)

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Impact of OASIS Accuracy

• OASIS accuracy is imperative for patient
  assessment care management
• OBQI Reports and Home Health Compare data are
  based upon agency self-reported OASIS data
• OASIS accuracy translates to each of the publicly
  reported quality measures, some of which will be
  incorporated by CMS for Pay for Performance for
  home health agencies

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Impact of OASIS Accuracy

• The accuracy of your OASIS assessment has a
  direct impact on care management, reimbursement
  and your agencys quality measure outcome data
• Care planning care coordination
• Currently publicly reported on Home Health
  Compare
• Potential impact on agency referrals
• Potential impact on Pay for Performance

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Strategies for Success

• Organizational Self Assessment OASIS Competency
• What does your agency do to ensure consistent and
  accurate OASIS data collection by both nurse and
  therapy staff?
• Does your agency have an OASIS competency
  requirement? If yes, how often is the competency
  renewed?
• How does your agency ensure ongoing OASIS
  training for current staff?
• How does your agency evaluate OASIS competency
  when new staff is hired?
• What tools / resources does your agency provide
  for staff to assist in accurately completing
  OASIS in the field?
• Does the agency have incentives for staff to
  answer OASIS accurately and to maintain
  competency?

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Strategies for SuccessPatient Assessment

• Combined Observation Interview Approach
• Observe patient opening medication containers
• Ask the patient to show and tell you how they
  open containers, fill a planner, use reminders
• Ask the patient to state the proper dosage for
  each medication and the correct times for
  administration
• The question does not consider the patients
  knowledge about potential side effects. This is
  part of the comprehensive assessment but not
  considered when responding to M0780
• Chapter 8 OASIS in Detail, Implementation Manual
  (December 2002), http//www.cms.hhs.gov/HomeHealt
  hQualityInits/14_HHQIOASISUserManual.asp)
• Oasis Webbased Training and CMS OCCB 8/2004
  QAs.OASIS Certificate and Competency Board
  (OCCB),http//www.oasiscertificate.org/displayasso
  ciationlinks.cfm

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Strategies for SuccessPatient Assessment

• Combined Observation Interview Approach
• Cognitive/mental status and functional
  assessments contribute to determine the
  appropriate response for this item
• If the patients ability to manage medications
  varies from medication to medication, consider
  total number of medications and total daily doses
  in determining what is true most of the time
• Chapter 8 OASIS in Detail, Implementation Manual
  (December 2002), http//www.cms.hhs.gov/HomeHealt
  hQualityInits/14_HHQIOASISUserManual.asp)
• Oasis Webbased Training and CMS OCCB 8/2004
  QAs.OASIS Certificate and Competency Board
  (OCCB),http//www.oasiscertificate.org/displayasso
  ciationlinks.cfm

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Strategies for SuccessPatient Assessment

• Ability Versus Preference Caregiver
• Patients caregiver may choose to organize a
  pill planner for patient to make things easier
  for the patient
• BUT
• accurate assessment should be based on whether
  the patient is able to organize pill planner

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Strategies for SuccessPatient Assessment

• Ability Versus Preference Residence
• Adult Home may be providing medications to the
  patient as per protocol
• BUT
• accurate assessment should be based on whether
  the patient is able to prepare and take their own
  prescribed oral medications reliably and safely

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Strategies for SuccessPatient Assessment

• Organizational Self Assessment OASIS Accuracy
• Are both observation and interview utilized for
  assessment of M0780?
• Do staff observe the patient performing
  preparatory activities (gathering med supplies,
  ability to access where meds are routinely
  stored)?
• Are both prescribed over-the-counter
  medications on the medication list?
• Is action taken when problems with oral
  medications are identified?

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OASIS AssessmentOral Medication
ManagementTools Resources
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Strategies for SuccessPatient Assessment Tools
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Home Health STAR Web Site OASIS Guidance
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Strategies for SuccessPatient Assessment Tools
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Included as a handout for todays presentation
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Strategies for SuccessPatient Assessment Tools

• http//www.homehealthquality.org
• Leadership Assessment
• Agency Assessment
• Action Plan Items
• Protocols
• Clinician Competency Test
• Implementation Tools

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Strategies for Success

• How can we improve our patients ability to
  manage their oral medications over the course of
  the home care episode?
• Utilize agency clinical staff to identify
  clinical activities / actions that might improve
  ability to manage oral medications
• Assessment
• Clinical Interventions / Teaching

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Importance of Medication Management

• Nearly one-third of all patients aged 65 older
  admitted to home care have evidence of a
  potential medication problem
• Decline in medication management is 2nd most
  frequently occurring adverse event
• Almost 30 of hospital admissions for people age
  65 or older are directly attributed to medication
  non- adherence
• 30-50 of hospital admissions are believed to be
  due to drug related problems or adverse events
• (Fanning 2005)

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Importance of Medication Management

• Approximately 40 of people are admitted to
  nursing homes because they are unable to safely
  manage their medications at home
• 5th leading cause of death for older adults
  7,000 deaths per year due to adverse drug events1
• Twenty percent of the Medicare population has
  five or more chronic conditions see 14 different
  physicians in a year fill 50 prescriptions
  annually and account for 2/3 of total Medicare
  spending
• 1. 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.

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Strategies for SuccessClinical Intervention

• Compliance
• Assess compliance barriers to compliance
• Assess patients understanding of medication
  purpose
• Older adults will take medications when they
  understand why they are on them trust the
  recommendation of the clinical team
• Assess cognitive function
• Assess support systems
• Patients with good support systems tend to take
  medications correctly
• Assess nutrition
• Assess GI function ability to tolerate
  medications

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Strategies for SuccessClinical Intervention

• Polypharmacy
• Older adults often take many medications that may
  increase the risk of ADRs increase the risk of
  hospitalization
• The number of medications often influences the
  patient or caregivers ability to manage
  medications accurately independently
• Multiple medications that cause sedation or
  sleepiness can interact to produce mental status
  decline

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Strategies for SuccessClinical Intervention

• Polypharmacy
• Incorporate medication reconciliation at SOC/ROC
  and review every visit
• Identify patients at risk for adverse drug
  reactions (ADRs)
• Multiple diagnosis
• Multiple healthcare providers

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Strategies for SuccessClinical Intervention

• Organizational Self Assessment Clinical
  Intervention
• Is medication reconciliation part of our
  assessment?
• Do we assess adherence to prescribed medications?
• Do we identify reasons for non-adherence and are
  appropriate referrals made to other disciplines
  to address?
• Is the pharmacy the patients uses identified?
• Do we coordinate with the pharmacy so that
  medication packaging compliance aids are
  compatible?
• For therapy only cases, do therapists evaluate
  medication adherence on an ongoing basis
  request an RN intervention if adherence problems
  are identified?
• Do we use a medication simplification protocol
  for patients on more than 8 medications?

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Clinical InterventionOral Medication
ManagementTools Resources
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Strategies for SuccessPatient Assessment Tools

• http//providers.ipro.org/index/homehealth_downloa
  ds
• Assessment protocols
• Teaching Tools
• Non-Adherence Guide
• Medication Reconciliation
• Medication Simplification

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http//www.homehealthquality.org
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Included as a handout for todays presentation
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Strategies for Success

• Improve OASIS assessment staff competency
• Utilize clinical intervention tools to address
• Non-adherence
• Medication reconciliation
• Polypharmacy
• Patient / caregiver understanding
• Patient / caregiver self-management

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Strategies for Success

• You can make a difference for your patients!
• Improved ability to self-manage medication
  administration
• Decreased risk of ADRs and potential
  hospitalization

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Additional Educational Resources

• IPRO Recorded Teleconference Sessions
• http//providers.ipro.org/index/homehealth
• Past Events Section
• Strategies to Reduce Avoidable Acute Care
  Hospitalizations Medication Management - 5/9/07
• Clinical Strategies to Improve Patient Outcomes -
  6/27/07
• Clinical Strategies to Improve Patient Outcomes
  Oral Medication Management Patient Falls -
  2/28/07
• Improvement in Oral Medication Management in Home
  Health Care - 3/22/06
• Improvement in Oral Medication Management
  Introduction to the New York State Initiative -
  03/14/06

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Website Resources

• HHQI Campaign Web site www.homehealthquality.org
• OASIS Training Web site-
• www.oasistraining.org/oasis11/upfront/U1.asp
• MedQIC Web site www.medqic.org
• IPRO Web site www.ipro.org
• Home Health STAR Web site http//www.medqic.org/
  hh/star

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QuestionsCommentsDiscussion
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For more information, contact

• Sara Butterfield, RN, BSN, CPHQ, CCM
• Director, Upstate Health Care Quality Improvement
• [phone] ext. 104
• sbutterfield_at_nyqio.sdps.org
• Christine Stegel, RN, MS, CPHQ
• Performance Improvement Coordinator
• [phone] ext. 113
• cstegel_at_nyqio.sdps.org
• Victoria Agramonte, RN, MS
• Performance Improvement Coordinator
• [phone] ext. 115
• vagramonte_at_nyqio.sdps.org

Corporate Headquarters 1979 Marcus Avenue, Lake
Success, NY 11042 Regional Office 20 Corporate
Woods Blvd., Albany, NY 12211
This material was prepared by IPRO, the Medicare
Quality Improvement Organization for New York
State, under contract with the Centers for
Medicare Medicaid Services (CMS), an agency of
the U.S. Department of Health and Human Services.
The contents do not necessarily reflect CMS
policy.



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