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, mtrufasiu@picf.org

► Sandy Atkins, Project Director - 818.837.3775 x111, satkins@picf.org

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