Veterans, Caregivers and Medication Management May 1, 2012

1. Veterans, Caregivers and Medication Management May 1, 2012

2. Presenters • Meg Campbell-Kotler, MPH, RN National Program Manager, Caregiver Education and Training Caregiver Support Program • Byron Parks, LCSW, LADC Caregiver Support Coordinator, VA Sierra Nevada Healthcare System –Reno • Jessi Wilson, MSW, LCSW Caregiver Support Coordinator, John J. Pershing VAMC

3. Veterans, Caregivers and Medication Management OUTLINE Caregiver Support Program - Overview Caregiver Training in Medication Management Medication Management and Caregiver Stress Case Studies

4. Veterans, Caregivers and Medication Management

5. Caregivers of Veterans Are Unique 80% live with the care recipient (23% non-VA caregivers) 30% providing care for 10 years or more (15%) 70% Veteran has mental illness or PTSD (28%) 68% high emotional stress (31%) 40% high physical strain (higher for women than men) 47% stopped working (9%) 50% high financial hardship (13%) *Caregivers of Veterans – Serving on the Homefront National Alliance for Caregiving, November, 2010

6. Caregivers of Veterans Report Symptoms of Stress Significant impact on Caregiver: • Increased stress or anxiety • Sleep deprivation • Less time exercising • Poor eating habits • Weight gain or loss • Depression • Delaying own health care

7. Caregivers and Veterans Omnibus Health Services Act of 2010 – Title I - Public Law 111-163

8. Assumptions • VA relies on Family Caregivers to maintain Veterans at home in the community • Family Caregivers face significant challenges • Supporting Caregivers helps Veterans • Caregivers are individuals with needs • Caregiver sensitivity and awareness is important in all programs • Integrating Family Caregivers as partners with treatment teams contributes to Veteran Centered Care

9. Current vs. New Caregiver Benefits Public Law 111-163 Current Benefits Available to Veterans of All Eras World War II Korean Vietnam Gulf War Post-9/11--------------------------------- • Education and Training • Family Support Services • In-Home Care • 30 Days of Respite Care • Aid and Attendance • Additional Benefits • Additional Benefits under P.L. 111-163 • Available to subset of post-9/11 Veterans and Servicemembers • Primary Caregivers Receive: • Stipend paid to Family Caregiver • Health care coverage (if not otherwise available) • Mental health services • Comprehensive instruction and training • Travel, lodging and per diem for training • Enhanced respite care • Lodging and subsistence for Veteran’s appointments at VA 8 8

10. Comprehensive Caregiver Support Services • Allow Veterans to remain at home in the community • Address specific needs of Family Caregivers with a menu of programs and services • Promote Veteran & Caregiver health and well-being • Provide one location to obtain needed information • Provide training & information on common conditions • Reduce isolation with professional & peer support • Provide options to give Caregivers respite • Sensitize health care providers to the Caregivers’ role

11. Eligibility Criteria - Caregiver Support Stipend Program - A Snapshot Veteran (or Servicemember undergoing medical discharge) incurred or aggravated a serious injury in the line of duty on or after September 11, 2001 (includes Traumatic Brain Injury, psychological trauma or other mental disorders) Requires on-going assistance from a Caregiver for a minimum of 6 months to: • 1. Support the Veteran or Servicemember’s health and well-being • 2. Perform personal functions required in everyday living; and • 3. Ensure the Veteran or Servicemember remains safe from hazards or dangers incident to his or her daily environment are additional criteria beyond what is listed here ** Note: There are additional criteria beyond what is listed here. ** Note:: there are additional criteria beyond what is listed here

12. Application Steps • Completion of 10-10 CG • Caregiver Interview • Veteran Assessment of Need for Assistance with ADLs and/or Supervision/Protection • Caregiver Completes Core Training Curriculum • In-Home Assessment of Caregiver and Veteran • Admission to Program

14. Caregiver Education and Training Standardized Core Curriculum • Developed in collaboration with Easter Seals • In-person, workbook/DVD, or web-based • Includes modules on: Caregiver Self-Care Home Safety Basic Caregiver Skills (med management) Providing Personal Care Managing Challenging Behaviors Resources (legal, financial, VA, community, advocacy) Training Data Update: • Over 4,500 Family Caregivers have completed training as of April 16

15. Medication Management in the Caregiver Curriculum Key Concepts • Caregivers are on the “front line” in documenting the Veteran’s response to medications • Observe changes in mood, diet, sleeping habits, skin etc. • Important to establish open lines of communication with the Primary Care Team • Times of transition increase risk for medication errors

16. Questions to Ask About Medications: • Purpose • How to Take – dosage, how often, how long, special time of day, with or without food, any foods to avoid • Othermedications to avoid while taking this medicine

17. Questions to Ask About Medications: • Side Effects – how to avoid or minimize, what to do • Efficacy – indicators that the medication is working

18. Transitions Require Increased Vigilance At Hospitalization - Bring an up-to-date list of current medications or bring medications During Hospital Stay – Ascertain that Veteran is receiving daily medications including those not related to hospitalization At Discharge – Ask questions, be certain that instructions are understood. Are new prescriptions replacing medications at home

19. Transitions Require Increased Vigilance At the Pharmacy – Check that the correct medication has been dispensed At Home – Write the name of the condition being treated on each medication container. Create or update the Veteran’s medication list

20. Maintain a Medication List • Medications prescribed by VA and Non-VA providers • OTC medications such as NSAIDS, Cold Medications etc. • Vitamins or Herbal Supplements • Maintain 2 copies – home and wallet

21. www.caregiver.va.gov

22. www.caregiver.va.gov/toolbox/staying organized

23. www.caregiver.va.gov/toolbox/staying organized

24. Medication Disposal Do not flush medications – Consult Pharmacist • Crush or dilute the medication • Place medication in plastic bag or container • Add kitty litter or coffee grounds to bag or container • Place into a second plastic bag, seal and place in trash

25. Caregiver Stress – Medication Management • Scant research on how Caregivers cope with medication management issues • Studies that look at the contribution of medication administration to Caregiver stress or burden report only a global measure • Slides to follow report more discreet findings: Medication Administration Hassles Reported by Family Caregivers of Dependent Elderly Persons, Travis, Shirley et. al. The Journals of Gerontology; Jul 2000

26. Caregiver Stress – Medication Management • Administering and managing medication regimens for a dependent older adult contributes to Caregiver Stress • Caregivers manage combinations of prescription and OTC medications for multiple chronic conditions • Multiple daily minor irritations – over-time may increase Caregiver stress

27. Caregiver Stressors – Medication Management • Scheduling • Planning around meal and bedtime routines work best when Caregiver has a predictable schedule • Caregivers employed or with other family/caregiving responsibilities find it more difficult to ensure that the care recipient does not miss doses • Difficulty administering large numbers of different medications throughout the day • Keeping multiple prescriptions filled – when multiple sources are used

28. Caregiver Stressors – Medication Management • Medication Administration • Most difficult if care recipient is cognitively impaired • Managing variable doses of medication • Decision making about medication administration – reducing or increasing doses, holding doses – nights, weekends and holidays difficult • Administering painful, embarrassing or noxious medications

29. Caregiver Stressors – Medication Management • Safety • Monitoring for adverse or toxic effects of medication • Especially if care recipient is unable to report problems or if adverse reactions begin in subtle ways • Concerns about recognizing emergency situations and knowing how to respond • Constant Vigilance

30. Support for Caregivers in Medication Management • Provide Caregivers with the What, When, How and Why for each medication • Assist Caregivers to develop critical thinking skills that would enable them to handle the ever-changing nature of long-term caregiving • VA has unique capacity to offer intentional, systematic support to Caregivers • Respite

31. Boomers as Caregivers • Less than 50% of Baby-Boomers know much about their parents’ medical histories or can name one of the medications taken by a parent on a regular basis* *The Role of Medications in the Lives of Older Adults: An Overview Clark, Thomas R. Generations Winter 2011-2012

32. Case Study - Marine . • 33 year old male H.S. Graduate • Some college before deciding to join the military • Served 10 years in the Marine Corps, completed 3 tours in Iraq • Planned to make the military a career • Medically discharged as a result of multiple injuries suffered in the line of duty • 100% Service Connected, but not designated as permanently disabled

33. Case Study – Marine (cont.) • Worries that he may lose his benefits • Married, with two children • No other local family support, other family members live out-of-State • Caregiver is his wife of 4 years • Wife is employed as well and would like to return to school to pursue a nursing degree

34. Case Study – Marine (cont.) Veteran has identified the following problems that are negatively impacting his quality of life, and for which he needs the support of a Caregiver These include: • Symptoms related to Traumatic Brain Injury • Symptoms related to PTSD • Insomnia • Chronic back pain • Chronic knee pain • Chronic bowel related problems • High blood pressure

35. Case Study – Marine (cont.) • Enrolled in the VA system 3 years ago • 2 Primary Care Providers in that time period • Inconsistent attendance at medical appointments • Psychiatrist for medication management • Refused referral to group citing discomfort in groups

36. Case Study – Marine (cont.) • Reports difficulty “tracking” provider recommendations, especially prescriptions • Veteran is frustrated after appointments as he cannot recall details • Feels uncertain about which medications are prescribed for which symptoms, and the recommended dosage

37. Case Study – Marine (cont.) • Veteran is concerned that he will be judged as “drug seeking” due to the frequency and dosages of his medications –especially for pain management • Veteran is also concerned about repeated courses of antibiotics he has been prescribed • Veteran also has a “medical marijuana card,” fromwhich he reports getting the “best relief” for appetite and sleep problems

38. Case Study – Marine (cont.) • Requesting a comprehensive diagnostic process, to thoroughly address the physical problems he has been experiencing • His ideal plan would be to: • Utilize collateral services, including physical therapy, chiropractic care, and recommendations for long-term self-guided physical rehabilitation • And “be seen as a professional athlete, which is what a soldier is, and to get the resources necessary to get back into the game; not someone who ends up depending on drugs”

39. Case Study – Marine (cont.) • Prior to entering the Caregiver Program, Veteran had decided to stop receiving health care from VA for everything but medications • Veteran felt that he wasn’t being “heard,” and that he didn’t understand the expectations or recommendations of his providers • Veteran now feels more supported and has a better grasp of recommendations since his wife has been become a partner in his care, regularly attends his appointments, and is included in care/medication decisions

40. Case Study – Marine (cont.)

41. Case Study - Chronic Pain • Sustained a back and neck injury during combat • Service Connected for Degenerative Arthritis of Spine and PTSD • Diagnosed with chronic pain • Manages pain and symptoms of PTSD with medication and complementary strategies such as light yoga and relaxation exercises • Pain medication prescribed does not offer sufficient relief

42. Case Study - Chronic Pain (cont.) • Pain medication runs out prior to refill date • Family Caregiver (Spouse) has advocated with primary care team regarding the Veteran’s increased pain and need for more medication • Both Veteran and Caregiver feel they are being viewed by team as “drug seeking” • Caregiver feels helpless

43. Case Study - Chronic Pain (cont.) • Physician wants Veteran to be seen in Pain Clinic located 3 hours away by car, to obtain additional guidance in managing the Veteran’s pain • Veteran refuses referral due to pain associated with sitting in a vehicle for long periods • Additionally expresses concern about being in a city with traffic and crowds

44. Case Study - Chronic Pain (cont.) Discussion • Caregiver Support Coordinator will follow up with the PACT – Patient Aligned Care Team • To share insights from psychosocial perspective and facilitate communication between Caregiver and PACT regarding the Veteran’s pain • Explore strategies to facilitate travel to the Pain Clinic • Consult with PACT on other options: Telehealth Evaluation, Alternative Pain Clinic or Chiropractic Services

45. Case Study – Female Veteran • Female Veteran – 62 yrs with hypertension for past 3 years • PACT Team has prescribed anti-hypertensive medication and a diuretic • Veteran monitors her blood pressure regularly and noted elevation for two days • VA CBOC is 60 miles from her home • Veteran’s spouse/Caregiver decides to bring her to a local private physician

46. Case Study – Female Veteran (cont.) • Veteran and Caregiver failed to bring a list of all medications to the new provider and report only taking a diuretic • New provider prescribes a new anti-hypertensive medication and adds a prn diuretic • Veteran now taking both VA prescribed medication plus meds prescribed by local physician • She complains of feeling dizzy and light headed and when attempting to stand loses balance and falls • Veteran is taken to VA Urgent Care 2.5 hours from home and admitted for low blood pressure

47. Case Study – Female Veteran (cont.) Discussion • Caregiver Support Coordinator follow up: • Collaborate with Veteran’s PACT and in-patient team in providing Caregiver Education on medication management • Caregiver expressed remorse re medication error – provided support • Utilize the medication log on www.caregiver.va.gov in working with Caregiver to keep an up-to-date list all the Veteran’s medications • Facilitated referral to HBPC for medication management • Ensure that the Caregiver has the direct telephone number for the Veteran’s PACT and knows that CSC can be contacted if PACT cannot be reached

48. Veterans, Caregivers and Medication Management QUESTIONS ?

49. Veterans, Caregivers and Medication Management Contact Information Meg Campbell-Kotler – margaret.campbell-kotler@va.gov 202-461-6085 Byron Parks -byron.parks@va.gov 775-328-1461 Jessi Wilson – jessi.wilson@va.gov 573-778-4545