Medication Management: A New Standard for Care Management Programs

1. Medication Management: A New Standard for Care Management Programs Sandy Atkins Project Director Mira Trufasiu Project Manager

2. 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

3. 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

4. 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.

5. 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

6. 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!

7. 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 • IOM (1999) To err is human: Building a safer health system. Kohn, L., Corrigan, J., Donaldson, M. (Eds.) National Academy Press, Washington D.C. • 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. • IOM (2006) Preventing Medication Errors.

8. 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

9. “Your condition has no symptoms or health risks, but there is a great new pill for it.”

10. 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.

11. Intervention – From Alerts to Action

12. 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.

13. 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%

14. Race/Ethnicity by Site(N=615)

15. Evidence of Effectiveness • 615 clients in 3 Medicaid waiver sites were screened • 49% (N=299) had potentialmedication 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.

16. 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) Potential Medication Problems by Type

17. # of potential problems increases with # of medications taken *p<.05, **p<.01, ***p<.001

18. Improvement after intervention

19. 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

20. Waiver Staff Perspectives on Project • Overall + responses to intervention & translation • Key differences • Nurse / Social Worker perspectives • Experience with EBP implementation • Location of care managers

21. 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”

22. 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”

23. 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

24. 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

25. 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

26. 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 Implementation Experience

27. Medication Management Tools • Tracking and recording medication alerts in an automated system • Medication intervention protocols • Health assessment • Vital signs • Progress notes

28. 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

29. 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.

30. 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.

31. 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

32. 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

33. 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

34. Collaborators Partners in Care Foundation Dennee Frey, PharmD June Simmons, LCSW Mira Trufasiu, MSG Sandy Atkins, MPA Jennifer Wieckowski, MSG Susan Enguidanos, PhD Huntington Hospital Senior Care Network Neena Bixby, LCSW Eileen Koons, MSW Lois Zagha, MA Pat Trollman, LCSW USC Andrus Gerontology Center Gretchen 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 Acknowledgements