The role of consultant pharmacists in reducing medication problems among older adults receiving Medicaid waiver services.

OBJECTIVE: To evaluate the impact of an evidence-based, medication management intervention to reduce four targeted medication problems among older adults at risk for placement in a nursing facility. DESIGN: A pretest-posttest design. SETTING: Three sites of California's Multipurpose Senior Services Program (MSSP), a Medi-Cal waiver care management program. PARTICIPANTS: Six hundred fifteen dual-eligible, functionally impaired, community-dwelling adults, 65 years of age and older, enrolled in MSSP between June 2004 and January 2006. INTERVENTION: In collaboration with care managers, consultant pharmacists confirmed medication problems, developed individualized treatment plans, recommended changes, and communicated recommendations to prescribing physician(s), care managers, and participants/caregivers. MAIN OUTCOME MEASURES: Change in participant's medication at three-month follow-up. RESULTS: Twenty-six percent (n=162) had a confirmed medication problem, and of those, 61% had at least one medication changed at three-month follow-up. Change rates for each medication problem ranged from 46% to 68%. Thirty-seven percent had two or more confirmed medication problems, and those with multiple medication problems had greater opportunity to realize at least one medication change. Pharmacists communicated with physicians, care managers, and participants/caregivers at varying levels; however, in 22 cases where all three parties were contacted, change rate was 73%. CONCLUSION: Findings illustrate that consultant pharmacist services, in collaboration with other community-based providers, can reduce medication problems for vulnerable community-dwelling elders using well-defined criteria. There are policy implications for cost and reimbursement mechanisms that may increase identification and resolution of medication problems among older adults in Medicaid waiver services.

Characteristics associated with four potential medication problems among older adults in Medicaid waiver services.

OBJECTIVE: To identify characteristics associated with four potential medication problems among older adults at risk for nursing home placement. DESIGN: Cross-sectional survey. SETTING: Three sites of California's Multipurpose Senior Services Program (MSSP), a Medi-Cal waiver care management program. PARTICIPANTS: Six hundred fifteen dual-eligible, functionally impaired, community-dwelling adults aged 65 years and older enrolled in MSSP between June 2004 and January 2006. INTERVENTION: Medication screening using the Home Health Criteria that include medication use and clinical risk factors. MAIN OUTCOME MEASURES: Demographic and health characteristics associated with four problem types: 1) unnecessary therapeutic duplication, 2) psychotropic medication use with concurrent falls or confusion, 3) cardiovascular medication problems, and 4) use of nonsteroidal anti-inflammatory drugs (NSAIDs) with risk of peptic ulcer complications. Independent measures included age, gender, race/ethnicity, living arrangement, number of medications, health status, and utilization. RESULTS: Each problem type was associated with different characteristics, as identified by logistic regression modeling. Increased number of medications was associated with therapeutic duplication (odds ratio [OR] = 1.27; confidence interval [CI] 1.20-1.35; P < 0.001) and problematic psychotropic medication use (OR = 1.15; CI 1.08-1.22; P < 0.001). Psychotropic use was also associated with emergency department, hospital, or skilled nursing admission in the previous year (OR = 1.86; CI 1.15-3.00; P = 0.012), living with someone (OR = 0.57; CI 0.34-0.95; P = 0.032), and new care management enrollment (OR = 1.99; CI 1.22-3.24; P = 0.006). New enrollment was also associated with cardiovascular medication problems (OR = 2.15; CI 1.32-3.51; P = 0.002). There were no significant characteristics associated with NSAID problems (not shown). CONCLUSION: Unique predictors of potential medication problems highlight the need for systematic medication screening and treatment planning. These should include medication therapy management for vulnerable community-dwelling elders (upon enrollment for care management) and for those taking multiple medications. Funding mechanisms via Medicare Part D (prescription drug program) should be explored in this population to increase identification of medication problems and their resolution.

Prevalence of potential medication problems among dually eligible older adults in Medicaid waiver services.

BACKGROUND: Methods for identifying potential medication problems among older adults at risk for nursing home placement have generally not included clinical risk factors in addition to medication lists. OBJECTIVE: To assess the prevalence of potential medication problems for older adults enrolled in a Medicaid waiver service using tested Home Health Criteria that combine medication use and clinical risk factors for screening drug regimens. METHODS: A cross-sectional survey screened 615 community-dwelling, dually eligible, functionally impaired adults aged 65 years and older enrolled in a Medi-Cal (California's Medicaid) waiver care management program, California's Multipurpose Senior Services Program (MSSP). Measures included prevalence and predictors of having 1 of 4 potential medication problems: unnecessary therapeutic duplication, use of psychotropic drugs with concurrent falls or confusion, cardiovascular medication problems, and use of nonsteroidal antiinflammatory drugs with risk of peptic ulcer complications. RESULTS: Forty-nine percent of the sample had a potential medication problem, with unnecessary therapeutic duplication being most prevalent (24%). Nearly 20% of patients screened had 2 or more potential problems. Independent predictors of any potential medication problem were age (OR 1.029; 95% CI 1.01 to 1.05), new MSSP enrollment (OR 1.634; 95% CI 1.14 to 2.35), and number of medications (OR 1.183; 95% CI 1.13 to 1.24). CONCLUSIONS: Prevalence of potential medication problems in MSSP was markedly higher than reported in the original home healthcare sample used to test the Home Health Criteria. The prevalence rate for older adults at risk for nursing home placement necessitates expanded screening and medication therapy management interventions, especially upon initial enrollment and for those taking multiple medications. Interventions are needed to increase medication problem identification and resolution while promoting collaboration among physicians, consultant pharmacists, and waiver service providers.

Implications of translating research into practice: a medication management intervention.

Through programs such as the Administration on Aging's Evidence-Based Prevention Initiative, researchers and practitioners are developing translational research studies seeking to implement rigorously tested, evidence-based interventions in new practice settings and evaluate the continuing effectiveness of these interventions. One such translational study is the Community-Based Medications Management Intervention (CBM Intervention), a collaborative effort to implement a medication management screening and intervention protocol in community-based waiver care management programs. The overall goals of the CBM Intervention are to implement an evidence-based medication management intervention in a California Medicaid waiver care management program, and to evaluate the effect of client-, intervention-, and organizational-level characteristics on resolving identified medication problems. This article presents the need for improved medication management in a frail, community-dwelling, older adult population and describes the CBM Intervention as an example of translating an evidence-based practice beyond its original efficacy trial in a home healthcare program into a care management program. It discusses critical factors involved in translating research into practice using a translational research framework, Promoting Action on Research Implementation in Health Services (PARIHS). Our experience suggests that although implementing research into practice can positively impact client care, professional skill enhancement and organizational effectiveness, this is very challenging work requiring signification facilitation for successful outcomes.

A quality improvement project to reduce falls and improve medication management.

This paper describes the implementation of a medication management model within a medical-center based home health agency. The model was integrated into the agency's quality improvement falls prevention program and was selected in part because it directly addressed two medication-related accreditation standards for home health care agencies. During a five-month period, a staff pharmacist conducted medication reviews for 228 HHA patients who met the program's inclusion criteria. Thirty-three percent of these patients required some type of follow-up to resolve potential medication-related problems. By far, falls were the most common reason for referral, with 71 patients, or 30% of all participating patients, referred to the pharmacist due to a recent fall. From a quality improvement standpoint, the program met and even exceeded expectations in that it enabled staff to identify a serious threat to patient safety-medication-related problems, especially falls--and gave them the tools to resolve these potential problems.

Integration of a medication management model into outcome-based quality improvement: a pilot program in a rural propriety home healthcare agency.

This article describes a rural proprietary home health agency's successful initiative to adapt a previously tested medication management model and integrate it into existing processes of care. The rationale to improve medication management in response to current national fiscal, clinical and external quality measures and evolution of this process in the agency is detailed. The agency refined the model's screening procedures, incorporating them into the mandated OASIS assessment and then computerizing the medication risk analysis, in keeping with the original intent of the model. In a four-month pilot test of the computerized risk assessment procedure 1006 OASIS assessments were screened; risk factors for medication-related problems in 201 (19.9%) resulted in pharmacist review. Of these, 30 (17%) were ruled out as potential medication errors, 143 (82.6%) were found with potential MRP and 58 (33.5%) had evidence of problems warranting follow-up. With this computer-assisted process, the agency created a more comprehensive assessment that was in line with the new regulatory emphasis on patient outcomes. Consultant pharmacist services also transitioned from drug regimen review to more comprehensive medication therapy management. By enhancing efficiencies in its medication management program, an agency not only stands to improve quality of care, but also to maximize resources, making the intervention affordable to implement and decreasing burden on staff.

Medication management: an evidence-based model that decreases adverse events.

Four diverse home care agencies are implementing a new Medication Management Model that has proven effective in preventing medication errors in elderly patients. The Model, available to all agencies, consists of advice from a consultant pharmacist to the attending nurse based on established guidelines. The Model's benefits for clinicians, agencies, and patients and how agencies can use it are described in this article.

Improving medication use in newly admitted home healthcare patients: a randomized controlled trial.

OBJECTIVES: To test the efficacy of a medication use improvement program developed specifically for home health agencies. The program addressed four medication problems identified by an expert panel: unnecessary therapeutic duplication, cardiovascular medication problems, use of psychotropic drugs in patients with possible adverse psychomotor or adrenergic effects, and use of nonsteroidal antiinflammatory drugs (NSAIDs) in patients at high risk of peptic ulcer complications. It used a structured collaboration between a specially trained clinical pharmacist and the patients' home-care nurses to improve medication use. DESIGN: Parallel-group, randomized controlled trial. SETTING: Two of the largest home health agencies in the United States. PARTICIPANTS: Study subjects were consenting Medicare patients aged 65 and older admitted to participating agency offices from October 1996 through September 1998, with a projected home healthcare duration of at least 4 weeks and at least one study medication problem. INTERVENTION: Qualifying patients were randomized to usual care or usual care with the medication improvement program. MEASUREMENTS: Medication use was measured during an in-home interview, with container inspection at baseline and at follow-up (between 6 and 12 weeks) by interviewers unaware of treatment assignment. The trial endpoint was the proportion of patients with medication use improvement according to predefined criteria at follow-up. RESULTS: There were 259 randomized patients with completed follow-up interviews: 130 in the intervention group and 129 with usual care. Medication use improved for 50% of intervention patients and 38% of control patients, an attributable improvement of 12 patients per 100 (95% confidence interval (CI) = 0.0-24.0, P =.051). The intervention effect was greatest for therapeutic duplication, with improvement for 71% of intervention and 24% of control patients, an attributable improvement of 47 patients per 100 (95% CI = 20-74, P =.003). Use of cardiovascular medications also improved more frequently in intervention patients: 55% vs 18%, attributable improvement 37 patients per 100 (95% CI = 9-66, P =.017). There were no significant improvements for the psychotropic medication or NSAID problems. There was no evidence of adverse intervention effects: new medication problems, more agency nurse visits, or increased duration of home health care. CONCLUSIONS: A program congruent with existing personnel and practices of home health agencies improved medication use in a vulnerable population and was particularly effective in reducing therapeutic duplication.

Preventing medication errors in home care.

This practice brief highlights the results of two home health care studies on medication errors. The first study determined how often medication errors occur in home health care. The second study tested a strategy to reduce these errors. Although nearly one third of home care patients are at risk for potential medication errors, adding a simple, practical program can reduce the potential for errors. These results should encourage home care agencies to be more vigilant in monitoring medication errors and to institute programs that help prevent errors from occurring.