improving medication management in home care:...

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Improving Medication Management in

Home Care: Issues and Solutions

April 28, 2015

Amanda Ryan, PharmD, CGP

Clinical Pharmacy Specialist

Meet J.C.

J.C. is an 88 year old

male.

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J.C.’s Story

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Admitted to hospital with stroke six weeks ago

Spent four weeks in a skilled nursing facility

Just came home with home health

Diagnoses:

CVA

type II diabetes

anxiety

insomnia

dementia

osteoarthritis

atrial fibrillation

COPD

depression

hypertension

dyslipidemia

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J.C.’s Medications

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Objectives: How We’ll Help J.C.

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Objective 1:

Commonly Misused/Abused Medications

and Prevention Strategies

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Medications Misused/Abused

by Elderly Patients

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American Society of Consultant Pharmacists (2013). STAMP OUT

Prescription Drug Misuse & Abuse. Alexandria, VA.

Prevalence as high as 11 percent

Older adults are especially vulnerable

Drug metabolism

Polypharmacy

Multiple prescribers and pharmacies

Multiple medical conditions

Hearing and vision problems

Cognitive decline

Common Medication Myths

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What Is Medication MISUSE?

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Use of a medication other than as prescribed or indicated

Usually unintentional

Taking too much or not enough

Taking medication too often

Forgetting to take medication

Taking medication for too long or not long enough

Sharing medication

May lead to medication ABUSE

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What Is Medication ABUSE?

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Intentionally taking medications incorrectly that are not

medically necessary, or for the experience or feeling a

drug causes

Taking more medication than prescribed

Taking medication more often than necessary

Mixing medication with alcohol or illegal drugs

Commonly Abused Medications

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Community Prevention Initiative, Center for Applied Research Solutions

(2008). The Elderly and Prescription Drug Misuse and Abuse. Santa

Rosa, CA.

Warning Signs of Medication Abuse

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Paying for medications out-

of-pocket rather than using

prescription drug insurance

Excessive worry about

whether mood-altering

drugs are “really working”

Increasing doses of

medications that “aren’t

helping anymore” or

supplementing prescribed

drugs with over-the counter

drugs

Abrupt behavior changes

Social withdrawal

“Doctor shopping”

Unexplained injuries

Sleeping during the day

Changes in grooming habits

Complaining that

prescribers refuse to write

prescriptions for preferred

medications



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How to Prevent Medication

Misuse and Abuse

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Assist with keeping a current medication list; take list to

ALL medical appointments

Educate patient to take medications exactly as

prescribed

Direct patient to prescriber or pharmacist for unanswered

medication questions

Address communication barriers

Ensure patient is taking only current medications

Use strategies to improve medication adherence

Improving Medication Adherence

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Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005

Aug4;353(5):487-97.

Home Health Quality Improvement (2010). Best Practice Intervention

Package, Improving Management of Oral Medications.

Patients must know what to do

Ask patient about his/her concerns first

Explain how the medication addresses the patient’s

condition

Provide simple and clear instructions on use of the

medication

Enlist help from prescribers and pharmacists as

needed

Use “Show Me” and “Teach Back”

Improving Medication Adherence (cont.)

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Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005

Aug4;353(5):487-97.



Patients must want to do it

Link anticipated outcomes to what is important to the

patient

Explain possible undesirable outcomes of non-

adherence

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Addressing Barriers to

Medication Adherence

Barrier Possible Strategies and Interventions

Fear of undesired effects Refer to prescriber, brief counseling

Limited literacy Visual model, audio recording, caregiver

assistance

Visual impairment Large print labels, OT referral

Dysphagia Swallowing evaluation, consult pharmacist

Motor skill impairment Easy open caps, bingo cards

Medication scheduling Consult prescriber to simplify medications

Memory disorder Rule out infection, alternative packaging

Lack of medication knowledge Clear instructions, “Show Me” and “Teach Back”

Medications inaccessible Work with caregiver on safe medication storage



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Back to J.C.

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Objective 2:

Polypharmacy and Medication

Regimen Complexity

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Polypharmacy

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No consensus definition

Use of multiple medications to treat a host of medical

conditions

“More medications than a patient can handle”

May include use of potentially inappropriate medications

(PIMs)

Beers Criteria

STOPP/START Criteria

Fewer medications may actually benefit patients

Beers Criteria

Lists PIMs for all older adults

Also lists PIMs that may exacerbate specific

medical conditions

American Geriatrics Society 2012 Beers Criteria Update Expert Panel.

American Geriatrics Society updated Beers Criteria for potentially

inappropriate medication use in older adults. J Am Geriatr Soc. 2012 Apr;60(4):616-31.

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PIM Rationale

Diphenhydramine,

hydroxyzine,

promethazine

SLUD (reduced salivation, lacrimation,

urination, deification), drowsiness, cognitive

changes

Nitrofurantoin Pulmonary toxicity, lack of efficacy if CrCl <

60 ml/min

Digoxin > 125

mcg/day

Potential toxicity, no benefit in heart failure

Antipsychotics Increased risk of stroke and death in

dementia patients

STOPP/START Criteria

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O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher

P. STOPP/START criteria for potentially inappropriate prescribing in

older people: version 2. Age Ageing. 2015 Mar;44(2):213-8.

Lists PIMs and possible prescribing omissions (PPOs)

Gives alternatives to PIMs and rationale for PPOs

PIMs PPOs

Long-acting benzodiazepines

(e.g. diazepam)

Warfarin for patients with

chronic a-fib

Glyburide Metformin for patients with

type II diabetes

Metoclopramide with

Parkinson’s disease

Inhaled corticosteroid for

moderate to severe asthma

or COPD

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Beyond Polypharmacy:

Medication Regimen Complexity

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Skaggs School of Pharmacy and Pharmaceutical Sciences. Electronic

Data Capture and Coding Tool for Medication Regimen Complexity.

http://www.ucdenver.edu/academics/colleges/pharmacy/Research/researchareas/Pages/MRCTool.aspx Accessed March 16, 2015.

Medication regimen complexity index (MRCI)

65-item tool

Considers multiple factors

Number of medications

Number of dosage forms

Dosing frequency

Additional directions

Consequences of Increased

Medication Regimen Complexity

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Schoonover H, Corbett CF, Weeks DL, Willson MN, Setter SM.

Predicting potential postdischarge adverse drug events and 30-day

unplanned hospital readmissions from medication regimen complexity. J Patient Saf. 2014 Dec;10(4):186-91

Schoonover et al., December 2014

High discharge medication MRCI increased odds of unplanned 30-day hospital readmission more than 5-fold (p = 0.026)

High home medication MRCI increased odds of possible ADE more than 4-fold (p < 0.001)

Discrepancies between discharge and home lists arose from patients deciding which medications they would or would not take

Discrepancies between discharge and home medications are common and increase potential for ADEs and hospital readmissions

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Medication Simplification Protocol – QMAP “Best Practices for

Improvement in Management of Oral Medications” OASIS

ANSWERS,

7 Steps to Medication Simplification

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J.C.’s New Medications

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J.C.’s New Medications

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Before After

Objective 3:

Using Care Coordination to Improve

Medication Safety for Elderly Home

Care Patients

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Medication Safety Definitions

Tower of Babel

Syndrome

Nebeker JR, Barach P, Samore MH. Clarifying Adverse Drug Events: A

Clinician’s Guide to Terminology, Documentation, and Reporting. Ann

Intern Med. 2004;140:795-801.

Medication Safety Definitions (cont.)

U.S. Department of Health and Human Services, Office of Disease

Prevention and Health Promotion. (2014). National Action Plan for Adverse

Drug Event Prevention. Washington, DC.

Medication Safety Definitions (cont.)

Term Definition Example

Adverse Drug Event

(ADE)

INJURY resulting from medical

intervention related to a drug. Most are

preventable.

Bleeding from Coumadin

overdose.

Adverse Drug Reaction

(ADR)

Harm directly caused by a drug at usual

doses. Causal link between the drug and

the harm.

Allergic reaction.

Medication Error Inappropriate use of a drug that may or

may not cause harm. Preventable.

Patient receives wrong

medication.

Potential Adverse Drug

Event (pADE)

Medication error that could potentially

lead to ADE, stopped before harm can

occur.

Patient has an order for a

medication to which he/she is

allergic, order changed before

patient takes the medication.

Nebeker JR, Barach P, Samore MH. Clarifying Adverse Drug Events: A

Clinician’s Guide to Terminology, Documentation, and Reporting. Ann Intern Med.

2004;140:795-801.

U.S. Department of Health and Human Services, Office of Disease Prevention

and Health Promotion. (2014). National Action Plan for Adverse Drug Event

Prevention. Washington, DC

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QIN-QIOs: What We Do

Bring Medicare beneficiaries, providers, and

communities together in data driven initiatives that

increase patient safety,

make communities healthier,

better coordinate post hospital care and

improve clinical quality.

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QIN-QIOs: atom Alliance

The QIO Program’s Approach

to Clinical Quality

Goals

Make care safer

Strengthen patient and family

engagement

Promote effective

communication and

coordination of care

Promote effective prevention

and treatment

Promote best practices for

healthy living

Make care affordable

http://www.aqaf.com/

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Coordination of Care

Care Coordination Goals

Reduce Medicare hospital admission and

readmission rates by 20 percent by 2019

Increase Medicare patients’ number of nights

spent at home post discharge by 10 percent

Reduce ADEs resulting from uncoordinated

transitions of care

atom Alliance

Care Coordination Communities

Communities across

atom Alliance have

been working to

accomplish these

goals.

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Medication Safety and

Coordination of Care

atom Alliance will

Recruit Medicare beneficiaries within established

care coordination communities

Must be taking three or more medications

One medication must be an opioid, diabetic agent

or anticoagulant

Provide medication safety training to providers

Provide educational activities and resources to

promote engagement of beneficiaries and caregivers

Medication Safety and

Coordination of Care (cont.)

Establish community relationships to coordinate provider

communication and medication therapy management

(MTM) across care settings with a patient centered focus

Use MTM tools to prevent ADEs and patient harm

Develop/promote evidence-based ADE prevention toolkits

for overall medication safety and specifically for

anticoagulants, diabetic agents and opioids

Identify community-specific barriers to ADE reduction

Work with communities to screen all recruited beneficiaries

for potential ADEs and ADEs

atom Alliance Helps Communities to

Implement evidence-based interventions to

reduce hospital admissions and readmissions

Track changes and progress using real-time and

claims-based data

Establish and use protocols and procedures to

track ADEs

Redesign workflow, to improve care coordination

between facilities

Assemble, lead or contribute to care coordination

communities

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atom Alliance Helps Communities by

Supporting and promoting community meetings and

care coordination activities

Hosting on-site and virtual learning events

Assisting facilities and communities in selecting

measures for quality reporting

Preparing data feedback reports and providing

technical assistance

Sharing the collective tools and resources of the

five-state atom Alliance

Learn More

Amanda Ryan, PharmD, CGP

Clinical Pharmacy Specialist

[email protected]

(615) 574-7244

Betty DeBlasio, RN

Quality Improvement Advisor

[email protected]

(615) 574-7200

www.atomAlliance.org

This material was prepared by atom Alliance, the Quality Innovation Network-Quality Improvement

Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and

Alabama, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the

U.S. Department of Health and Human Services. Content presented does not necessarily reflect CMS

policy. 15.ASC32-ADE.03.002

mailto:[email protected]






http://www.atomAlliance.org

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