Looking for a Cheap and Easy Evidence-Based Program?

1. Looking for a Cheap and Easy Evidence-Based Program? • Partners in Care Foundation • June Simmons, CEO • Sandy Atkins, VP, Institute for Change

2. Presented By: • Sandy Atkins, VPInstitute for Change Partners in Care Foundation • Amy Adams,Manager Support Services B.S. Area Agency on Aging of Tarrant County (AAA) • Jennifer Severance, PhD Senior Citizen Services (SCS) • Samantha Powell, M.S., R.D.N., L.D. Meals On Wheels, Inc. of Tarrant County (MOWI)

3. Objectives • Understand HomeMeds • Recognize the benefits of the HomeMeds program • Learn strategies for implementing HomeMeds involving multiple partners

4. Agenda • Introducing Home Meds • Medication Problems • Benefits • The Process • Costs • Implementation • Partner Agencies • Software Demo • Q&A

5. Partners in Care FoundationWho We Are • Partners in Care serves as a catalyst for shaping a new vision of healthcare by partnering with organizations, families and community leaders in the work of changing healthcare systems, changing communities and changing lives—focusing on home and community care • We evolved from the VNA of Los Angeles to be a nimble force for change.

6. The Problem Medication Errors are: • Serious: Over 700,000 people go to ED each year for adverse drug events • Costly: Drug-related morbidity/mortality $170 billion -ER, hospital/readmissions, SNF etc. • Common: Up to 48% of community-dwelling elders have medication-related problems • Preventable: At least 25% of all harmful adverse drug events are preventable

7. The Solution: HomeMeds℠ HomeMeds is designed to enable community agencies to keep people at home & out of hospital by addressing medication safety Practice change with workforces/settings that already go to the home – more cost effective use of existing effort Focus on potential adverse effects (falls, vitals, confusion) … then determine if medications may be part of the cause

8. HomeMeds: Bridge from Home to Healthcare “Any symptom in an elderly patient should be considered a drug side effect until proved otherwise.” (Gurwitz et al. 1995)

9. Expected Results

10. HomeMeds℠: Saves Money, Saves Lives • Falls and other adverse effects improved through collaboration between pharmacists and members of the care team • 46.7% of older adults screened in 14 sites from 2007 to 2010 had risk for medication-related injury • Estimated Savings from 7,000 Screenings: up to $1.5 million. HRSA, 2010, www.hrsa.gov/patientsafety

11. HomeMeds℠ Evidence-Based Recognition • AoA recognition as an evidence-based prevention program –Highest Level of Evidence • National Registry of Evidence-based Programs and Practices (http://nrepp.samhsa.gov) (soon to be published) • Quality of research: 3.2/4 • Readiness for dissemination: 4/4 • US Agency for Healthcare Research and Quality (AHRQ) Innovation Exchange • Strong evidence rating http://www.innovations.ahrq.gov/content.aspx?id=2841

12. Risk-Screening Protocols • Identified by national expert consensus panel ¹ • Targets problems that can be identified and resolved in the home: • Positive response by prescribers • Minimize “alert overload”: based on signs/symptoms. • Unnecessary therapeutic duplication • Use of psychotropic drugs in patients with a reported recent fall and/or confusion • Use of non-steroidal anti-inflammatory drugs (NSAID) in patients at risk of peptic ulcer/gastrointestinal bleeding • Cardiovascular medication problems -High BP, low pulse, orthostasis and low systolic BP Limited to only these medication-related problems • ¹A model for improving medication use in home health care patients . Brown, N. J., Griffin, M. R., Ray, W. A., Meredith, S., Beers, M. H., Marren, J., Robles, M., Stergachis, A., Wood, A. J., & Avorn, J. (1998). Journal of the American Pharmaceutical Association, 38 (6), 696-702.

13. HomeMeds Intervention Process

14. Roles of the pharmacist Screen alerts to confirm problems Communicate with prescribers Consult with care manager Identify problems beyond protocols Assist with complex cases Educate staff about medications/risks

15. What does it cost? • Planning, setup, consultation, support: • $3,000, one-time fee • Software license • From $200/month for up to 50 new clients created/mo. • Negotiate shared licenses for smaller sites • Training • $5,000 on-site plus travel (shared multisite OK) • $250 per refresher webinar (after year 1)

16. Covering the Cost • Software, Startup & Pharmacist • Older Americans Act Title III-D • Pharmacist coverage alternatives • Pharmacy School – students & supervision • Waiver purchase-of-service dollars • Volunteer community pharmacist • Medicare MTW: Medication Therapy Management (through local pharmacy or patient’s Part D plan)

17. Who’s Implementing HomeMeds? • Medicaid 1915(c) Waiver programs for Dual Eligibles • Care Transition programs • CBO under contract with medical groups • Area Agencies on Aging & Senior Centers • Meals on Wheels • Home Health/Homecare Agencies • Assisted Living & Affordable Housing • Native American Tribal Community

18. HomeMeds at AAAAmy AdamsManager, Support ServicesArea Agency on Aging ofTarrant County

19. HomeMeds: Innovative adaptations & sustainability

20. Why should non-healthcare agencies work on medication safety? • Medications are a huge factor in readmissions and fall related injuries • A view into one’s home provides unique perspective otherwise unavailable to healthcare providers • Home medication reconciliation is a national patient-safety goal

21. Medications & Care Transitions • 72% of post-discharge adverse events are related to medications-and close to 20% of discharged patients suffer an adverse event * • Medication reconciliation and risk assessment is a core element of every care transition intervention Why wait for a hospitalization? Why not intervene earlier? *from Mary Andrawis, PharmD, CMMI, presentation to Drug Safety Panel, May 10, 2011 (cite Forster et al. Annals of Internal Medicine. 2003; 128: 161-167. / CMAJ FEB 3, 2004; 170 (3)

22. Partners in Care AAA/UW SCS MOWI • Congregate program • Safe Communities/ Fall Prevention • A Matter of Balance • Ft. Worth Fire Department • Medstar-Emergency Responder • Homebound clients • Hospital referrals • Medstar-Emergency Responder

23. Home visits uncover many “secrets”… of which physicians may not be aware OTCs – Over-the-counter medications Prescriptions from other other providers Adverse effects such as falls, dizziness, confusion Adherenceissues Out of system meds: Drugs from other countries, borrowed, Wal-Mart $4

24. Consumer Feedback… Mr. Johnson went from 20 meds to just 8: “You have saved us money on monthly refills and my life! We cannot thank you enough!”

25. AAA in Tarrant County, TX • Caregivers have positive response “….Beneficial to gain better understanding of their loved ones’ medications and provides confidence when accompanying them to doctors visits” • Don Smith, Director, Tarrant County AAA: “HomeMeds is the easiest of all evidence-based programs to implement. We can see results - decrease in number of medications, decrease in falls pre & post.” 25

26. HomeMeds at Senior Citizen ServicesJennifer Severance, PhD

27. HomeMeds in Congregate Settings Senior Citizen Services • Locations: • Senior centers • Faith-based organizations • Senior housing • Licensed Clinical Social Worker • Senior center directors • Social work interns

28. HomeMeds in Congregate Settings • 64% with low to medium medication adherence • 57% with at least 1 alert • 43% with unnecessary therapeutic duplication • 35% with increased risk of falls or dizziness

29. Lessons learned • Individual factors • Side effects, cost savings, supplement use • Person-centered resolutions • Non-medical options • Implementation factors • Privacy issues • Common refusals • Enhancing social services and partnerships

30. ‘Add-on’ to other recognized Evidence Based Programs: HomeMeds in Congregate Settings “HomeMeds integrates really well with CDSMP and MOB. Each has a module on medication management and HomeMeds reinforces this and integrates and is easy to refer people to.” 30

31. HomeMeds at MOWISamantha PowellM.S., R.D.N., L.D.Registered/Licensed Dietitian

32. MOWI HomeMedsMeals on Wheels of Tarrant County, Inc. • Homebound clients • Certified Pharmacy Tech (CPhT) • Track fall history for clients with alerts

33. What we are seeing at MOWI…. • Several doctors • Several pharmacies • Miscommunication between doc and client • Nutritional supplements • OTC drugs

34. MOWI HomeMedsOctober 2012-April 2013 1038 Clients 554 Clients with alerts (53%) 1133 Total number of alerts 247 Alerted clients with a fall history 342 Number of dizziness/fall alerts

35. Alerts and Fall History Fall History 1038 clients

36. Dizziness/ Fall alerts(1132 Total Alerts)

37. Costly Mistakes Hip & Thigh Bone (JPS) $53,247 (7 days) Shoulder, Wrist, Hand (JPS) $31,148 (2 days) Rehabilitation: (HealthSouth) $17,187 (10 days) Total Cost = $70,434 HomeMeds Cost: $50

38. Common Interactions Clients with hypertension taking Lopressor (metoprolol) as well as Calan (verapamil) Are at increased risk for: Congestive Heart Failure Severe high blood pressure Rapid heartbeat Fainting Severe Chest Pain

39. Costly Mistakes Chest Pain Total Cost = $17, 070 HomeMeds Cost: $50

40. Bringing it Home With Stories of Success Mrs. P • 56 years young • 3 grocery bags full of med bottles • 26 different medications found • 10 alerts generated • Doc only prescribed 11

49. Conclusion HomeMeds is a proven tool for improved medication safety, health and well-being for older adults. It is an affordable, evidence-based program that is a perfect bridge for partnerships between community agencies and healthcare.

50. HomeMeds: Call us or email us! Email us at HomeMeds@picf.org HomeMeds Website: www.HomeMeds.org HomeMeds Information Packet: http://www.homemeds.org/landing_pages/14,3.html Partners in Care Website: www.picf.org Sandy Atkins, VP: satkins@picf.org Phone: 818.837.3775