detecting & improving medication use among vulnerable elders: a community-based medication...

Detecting & Improving Medication Use Among Vulnerable Elders:

A Community-Based Medication Management Intervention

Gretchen AlkemaVA Greater Los Angeles Healthcare System

Kathleen WilberUSC Andrus Gerontology Center

June Simmons, Sandy Atkins, Mira Trufasiu, & Dennee FreyPartners in Care Foundation

Gerontological Society of America MeetingNovember 19, 2007

AcknowledgementsCollaborators

USC Andrus Gerontology CenterKathleen Wilber, PhD

Partners in Care FoundationDennee Frey, PharmDJune Simmons, CEO/LCSWMira Trufasiu, MSGSandy Atkins, MPASusan Enguidanos, PhD

Huntington Hospital Senior Care NetworkEileen Koons, LCSWLois Zagha, MFT

Funding Support

Administration on Aging Evidence-Based Prevention Initiative (#90AM2778)

John A. Hartford Foundation Doctoral Fellows Program in Geriatric Social Work

AARP Scholars Program

VA Postdoctoral Fellowship (#TPP 65-007)

Problem of Medication Errors 65+ = 12% of population but consume ⅓ of all drugs

19 - 48% elders in community w/ med-related problems

7,000 deaths annually by adverse drug events

Associated hospital costs = $2 billion

¼ of adverse drug events are preventable

Evidence-Based Practice (EBP)in a New Setting

Implemented tested medication management protocols from:

Medicare home healthcare RCT

to…

Medi-Cal waiver care management

Home Healthcare Context

Site: Medicare-certified home healthcare

Population: 65+ w/ skilled nursing need & MD orders

Staff: Nurses w/ pharmacist support

Length of Stay: Up to 6 weeks

Contact: Up to daily visits

Care Management Context

Site: Medi-Cal waiver care management

Population: 65+ dual eligibles w/ functional impairment

Staff: Nurses & social workers w/ pharmacist support

Length of stay: 1 month to 3+ years

Contact: Phoned monthly & quarterly home visit

Care Management Sample (N=615) Site #1: n=216

Site #3: n=126

Site #2: n=273

Targeted Medication Problems (Brown et al., 1998, Meredith et al., 2001)

1. Unnecessary therapeutic duplication

2. Psychotropic drug use w/ confusion or falls

3. Cardiovascular medication problems

4. Use of non-steroidal anti-inflammatory drugs (NSAIDs) with peptic ulcer risk

Research Design

Time 1 Time 2

3 Months

Prevalence

1. Screen for medication problems using theHome Health Criteria

2. Pharmacist confirms problem

3. If Yes, Pharmacist & CM develop care plan

4. Contact prescribing MD

5. CM discusses problem & solution with participant and/or caregiver

6. CM follow up to identify changes

· Was medication problem resolved?

· If yes, what was changed?

· If no, why not & follow up plan?

Care Management Sample (N=615)

81 years old

80% female

53% widows

40% lived alone

36% new to care management

Photo by Rollin Riggs, NY Times

Race/Ethnicity by Site (N=615)

0.0%

20.0%

40.0%

60.0%

80.0%

Caucasian African-American

Latino/a Asian/PI Other

Site #1

Site #2

Site #3

Language Preference (N=615)

Other11%

Chinese2%

Armenian6%

Spanish22%

English59%

Health Status (N=615)

Mean # of meds = 8.76 (SD=4.3); 12+ meds = 22%

38% ED, Hospital, or SNF in previous year

22% falls in previous 3 months

27% dizziness

31% confusion

Screened 3 MSSP Sites using Home Health Criteria:

615 Participants


615 Participants

Potential Medication Problems:

299 Participants (49%)

No Potential Problems:316 Participants (51%)


615 Participants



Confirmed Medication Problems:


Problem Not Confirmed: 118 Participants· False Positive: 83 · Unconfirmed: 25· Terminated from MSSP: 10


Pharmacist Review


615 Participants







Pharmacist Review

Terminated from MSSP: 19 Participants

Intervention Group:162 Participants (26.3%)


615 Participants







Pharmacist Review

Terminated from MSSP: 19 Participants

Intervention Group:162 Participants (26.3%)

3-Month Follow Up forMedication Improvement:

99 Participants

(61% of Intervention Group)

Attrition

10 left before med problems confirmed ↑ fallers (p<.05)

100% w/ 1+ potential problem (p<.001)

19 left before intervention completed ↓ # of meds (p<.05)

Main reasons: LTC, died, or moved

Prevalence Results (N=615)

Potential Confirmed

Medication Problem N % N %

Any 299 48.6% 181 29.4%

Ther. Duplication 149 24.2% 87 14.1%

Psychotropic 88 14.3% 65 10.6%

Cardiovascular 87 14.1% 27 4.4%

NSAIDs 79 12.8% 53 8.6%

Associated Characteristics

Any problems ~ ↑ age, new enrollment, & ↑ meds

2+ problems ~ ↑ meds

Therapeutic duplication ~ ↑ meds

Psychotropic ~ living w/ someone, new enrollment, ED/hospital/SNF, & ↑ meds

Cardiovascular ~ new enrollment

Problems by # Meds

0%

10%

20%

30%

40%

50%

1-3 4-6 7-9 10-11 12+

# of Medications

% o

f S

amp

le

AllProblems***

2+Problems***

TherapeuticDuplication***

Psychotropicw/ Falls*

Screening to

InterventionMedication Change

at 3 Months

(N=615) (N=162)

Medication Problem N % N % ∆

Any 162 26.3% 99 61.1%

Ther. Duplication 79 12.8% 49 62.0%

Psychotropic 59 9.6% 23 67.6%

Cardiovascular 24 3.9% 11 45.8%

NSAIDs 44 7.2% 22 50.0%

Intervention Results (N=162)

Staff Comments “As a SW, I became aware of potential dangers

or complications of some medications; I now look at all medications my clients are taking”

“No or slow response from the doctor…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”

Conclusions

Med problems highly prevalent in Medi-Cal waiver sample

Intervention successful in care management

Critical need for meds management across continuum of care

Payment sources for meds management

Next Steps Disseminate Medication Management Improvement

System ~ funded by Hartford Foundation

Computerized screening for potential problems Integration into MSSPCare (by RTZ Associates) Stand alone online version & algorithm for other software

Statewide replication in MSSPCare sites

National replication -- 2+ states NCOA Readiness Tool Seeking potential sites for 2008

Photo by JL Forter

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