Introduction to the Oral Medication Management Statewide Initiative

1. Introduction to the Oral Medication Management Statewide Initiative March 14, 2006

2. Objectives • Review the components of the management of oral medications quality measure • Review the Oral Medication Management Improvement Matrix & its application to Plan of Action Development • Discuss the Oral Medication Management Planning Packet • Discuss application of the OBQI process & identify strategies to improve this outcome • Identify resources to support agency performance improvement efforts

3. Historical Perspective: Oral Medication Management Quality Measure Rates • Launch of Home Health Compare (11/2003) • National Average – 35% • NYS Average – 38% • Most Recent Update of Home Health Compare (12/2005) • National Average – 40% • NYS Average – 42% • CMS 8th Scope of Work Goal (2008) – 90%

5. OASIS Item M0780(Source: OASIS Implementation Manual – Chapter 8 12/02 (M0780) Management of Oral Medications: • Patient’s ability to prepare and take all prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. • Excludes injectable & IV medications. • (NOTE: This refers to ability, not compliance or willingness.)

6. OASIS Item M0780(Source: OASIS Implementation Manual – Chapter 8 12/02

7. OASIS Item M0780(Source: OASIS Implementation Manual – Chapter 8 12/02) • “Prior” column should describe the patient’s ability 14 days prior to the SOC (or resumption) of care visit. • “Current” column should describe what the patient is ABLE to do today.

8. OASIS Item M0780(Source: OASIS Implementation Manual – Chapter 8 12/02) • “Unknown” is an option only in the “prior” column • Only medications whose route of administration is PO should be considered for this item • Medications given per gastrostomy (or other) tube are not administered PO, but are administered “per tube.”

9. Calculation of Outcome Rates • OASIS data from SOC/ROC AND discharge/transfer during the specified 12-month time period • Numerator – all episodes that had the outcome (potential to improve) • Denominator – all eligible episodes • Optimal status at SOC / ROC is excluded – (NOT a “0” for MO780)

10. OBQI Plan of Action Development “How can we improve our patients’ ability to manage their oral medications over the course of the home care episode?” • Utilize agency clinical staff to identify clinical activities / actions that might improve ability to manage oral medications: Assessment Clinical interventions/teaching Care planning/coordination

11. Oral Medication Management Planning Packet • Oral Medication Management Improvement Matrix on CD ROM • Oral Medication Management Tools & Resources on CD ROM • Process of Care Investigation Clinical Record Audit Tool • Plan of Action Template

12. Oral Medication Management Planning Packet • Instructions for navigation through the Patient Tally Workbook on the CD ROM incorporated into the Acute Care Hospitalization Planning Packet forwarded in October. • A hard copy of sample intervention strategies • A resource guide of best practice tools including a medication assessment protocol, staff educational tools addressing medication non-adherence, teaching strategies, the Medication Simplification Protocol, Beers Criteria, medication compliance aids, care planning tools and a patient educational tool for medication management.

13. Oral Medication Management Improvement Matrix Tools & Resources

16. Improvement Matrix:Areas for Improvement • Promoting Patient Self-Management • Implementing Evidence-Based Practices & Guidelines • Using Systems and Technology to Promote Effectiveness and Efficiency • Improving Care Delivery Systems & Mobilizing Community Resources • Creating a Culture of Quality

17. Oral Medication Management Improvement Matrix: Definitions • Change Framework – entire set of change concepts organized into Areas for Improvement and Stages of Care • Improvement Matrix – “big picture” of the organization and high-level strategies • Strategy – high-level change concept; represents a series of actions designed to achieve a specific objective • Action – specific change idea that can be tested and implemented at the agency level • Tool – a form, instrument, or manual that can be used as is or modified to support strategies and actions • Resource – a reference for more information related to implementing specific strategies and actions

18. Strategy Example: Using Systems & Technology to Promote Effectiveness & Efficiency Strategy C.2: Use systems to enhance effective internal and external communication and continuity of care - Staff communication within and between disciplines (including paraprofessionals), between office-based and frontline staff - Communication with key physicians - Communication with patients/families

19. Strategy C.2: Actions, Tools, Resources & Rationale

20. Application of the Improvement Matrix to OBQI Process

21. Act Plan Study Do Act Plan Study Do Act Plan Study Do OBQI Outcome Enhancement Process Collect & transmitOASIS data Monitoractionplan Measurepatientoutcomes Interpretoutcomereports Implementaction plan Specifytargetrate Developaction plan Identifyproblems/strengthsand best practices Investigatecareprocesses

22. OBQI and the Improvement Matrix • Where & how to start – key issue • Comprehensive Change Framework • Represents excellent system of care required to make transformational change • Not intended to do everything • Add strategies over time • Issues not the same in every agency • The OBQI process with some additional diagnostic tools can help narrow the focus

23. Next Steps for Plan of Action Development Interpret Outcome Reports & Specify Target Rate for Agency • Major Component of Plan of Action development • Compare agency risk-adjusted rate to other agencies in state & other benchmarks • Expectations for reductions should be based on agency’s baseline rate (Agency Trend Report) • Average rate is not necessarily the goal

24. Next Steps for Plan of Action Development Conduct Process of Care Investigation • Utilize the ACH chart audit tool or clinician interview guide • Randomly select up to 30 patient care episodes • Review the care episodes • Summarize findings

25. Patient Tally Report Workbook • Excel-based tool • Contains raw OASIS data for all of the patients included within your OBQI report • Combines your Case Mix Tally and Outcome Tally Reports into one tool • Allows you to query your OASIS data to determine case mix & patient outcome information

27. Patient Tally Report Workbook • Open up Patient Tally Workbook • Select second option on menu – “Create New Query on Existing Spreadsheet Data” • Follow Patient Tally Report Instructions provided in Oral Medication Planning Packet to create query of patients who both achieved & did not achieve improvement in oral medication management

28. Patient Tally Report Workbook • Select 30 patients to perform a record review utilizing the Audit Tool included in the Oral Medication Planning Packet

29. Oral Medication Management Clinical Record Review Tool

30. Agency Decisions • Determine the review format • Determine who will conduct the review • Determine the cases to be reviewed • Determine the review time frame

31. Pitfalls to Avoid During Process of Care Investigation • Premature closure (jumping to conclusions) • Involving only agency management • “Blaming” data collection or analysis methods • Not focusing on care delivery

32. Drawing Conclusions: • Compile team member tally sheets • Aggregate results • Summarize problem area(s)

33. Develop Problem Statement(s) • Describes specific aspect(s) of care that demonstrate opportunities to improve care • Contains specific, concrete wording to which clinical staff can relate • Addresses issues within the agency’s control • Focuses on patient care delivery instead of documentation • Contains a sufficiently narrow focus to keep a plan of action manageable

34. Identify Best Practices • Identify the problem or strength • Specific strategies from the Improvement Matrix can be considered for clinical best practices, especially those from • Promoting patient self-management • Implementing evidence-based practices and guidelines

35. Considerations for Action Plan Development • Staff Interpretation of OASIS Question & Response Selection • Multidisciplinary involvement to address oral med management • PT, OT, ST, Social Work, HHA & Pharmacist • Reference tools for staff guidance & communication • Beers Criteria • Medication Assessment Protocol • Medication Simplification Protocol • Educational tools addressing medication non-adherence • Teaching strategies • Medication compliance aids & care planning tools • Patient educational tools for medication management

36. Considerations for Action Plan Development • Medication Reconciliation • Organize an interdisciplinary team to develop/review policies for medication management • Ensure a list of patient’s current medications is received at time of referral • Develop a standardized trigger tool/interview guide to assist staff in obtaining all medication information • Provide education to therapists & nurses on medication reconciliation • Thoroughly assess medication history by examining all medication vials in home (including OTC containers) • Reconcile medications at all transition points during the patient’s episode (post ED, recert, post MD appt) Source: Ketchum, K., Grass, C. A., Padwojski, A. (2005). Medication reconciliation. American Journal of Nursing, 105 (11), 78-85

37. Intervention Actions • What is to be Done • When it is to be Done • Who is Responsible • How Action is to Monitored

38. Implement the Action Plan • Clinical staff informed • Responsible persons carry out intervention activities • Specified activities occur as planned

39. Monitor the Action Plan • POA is a dynamic tool • Emphasize small test of change before full-scale implementation • Monitor • Intervention actions occurred • Best practices are used consistently • Outcome

40. Tips for Internal Monitoring • Monitor your measures over time • Assign responsibilities for data collection • Utilize all staff levels for record review • Establish a schedule and process for data collection • Consider real-time data collection • Integrate data collection into ongoing work

41. Next Steps • Discuss with Team • Further investigation? • Finalize POA • Implement POA • Conduct Small Tests of Change • Measure & Monitor • Work Collaboratively with IPRO and other HHAs

42. Goals • Submit Oral Medication Management Plan of Action to IPRO no later than 05/01/06, for review and comment

43. Website Resources • MedQIC Website – www.medqic.org • IPRO – www.ipro.org • Joint Effort New York (JENY) Website - http://jeny.ipro.org • Home Health Compare - www.medicare.gov/hhcompare/home.asp

44. Contact Information Sara Butterfield , RN, BSN, CPHQ, CCM / Project Director Phone: 518-426-3300 ext. 104 Email: sbutterfield@nyqio.sdps.org Christine Stegel RN, MS, CPHQ /Performance Improvement Coordinator Phone: 518-426-3300 ext. 113 Email: cstegel@nyqio.sdps.org Susan Hollander MPH, CPHQ / Assistant Director Phone: 516-326-7767 ext. 241 Email: shollander@nyqio.sdps.org

45. Questions Feedback Sharing Recommendations