Adaptable, Evidence-based Medication Safety Improvement Intervention: Opening the door to CBO-Healthcare Partnerships Partners in Care Foundation Sandy Atkins, VP, Institute for Change Dennee Frey, PharmD, Program Consultant
Agenda • Introduce Partners in Care & HomeMeds • Contribution community agencies can make to medication safety using HomeMeds • The evidence base and the intervention • The software • User experiences & innovative applications • Getting started with HomeMeds • Q & A
Partners in Care Foundation Who 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.
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 use, 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
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.
“Any symptom in an elderly patient should be considered a drug side effect until proved otherwise.” ( Gurwitz et al. 1995) HOMEMEDS: BRIDGE FROM HOME TO HEALTHCARE
Why should non-healthcare agencies work on medication safety? • To thrive, CBOs need to play a new role connecting the home with the healthcare system – Medications are a huge factor in readmissions – Home provides unique perspective otherwise unavailable to healthcare providers – New focus on population health – identifying and proactively addressing health for high-risk patients – Quality measures for health plans and providers relate to issues such as medication use and fall prevention – Home medication reconciliation is a national patient-safety goal
Medications & Care Transitions *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)
Home visit uncovers many “secrets”… that prescribers may not know about • OTCs – Over-the-counter medications • Prescriptions from other other providers • Adverse effects such as falls, dizziness, confusion • Adherence issues • Out of system meds : Drugs from other countries, borrowed, Wal-Mart $4
Quality Measures Now Tied to $$$ • Star Ratings – Medicare Advantage – Yearly review of all medications and supplements being taken – Yearly pain screening or pain management plan – Controlling blood pressure – Reducing risk of falling – Readmission to a hospital within 30 days of being discharged • HEDIS for physicians – Percentage of Medicare members 66+ who received at least one high-risk medication – Fall Risk Management: Discussion & Management – Potentially Harmful Drug-Disease Interactions
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
ROI for MTM Medication Therapy Management • Five core components of MTM 12:1 ROI Highly targeted MTM in Medicaid Health Plan – General MTM has ROI of 1.5:1 to 4:1. – Cost: $240 per patient – Savings: $3,235 per patient (net of admin cost, copays, etc.) in decreased utilization (facilities, professional services, and prescriptions) Clinical and economic outcomes of medication therapy management services: the Minnesota experience. Isetts BJ, Schondelmeyer SW, Artz MB, Lenarz LA, Heaton AH, Wadd WB, Brown LM, Cipolle RJ. J Am Pharm Assoc, 2008 Mar-Apr;48(2):203-11;
Expected Results Lower Cost Fewer falls, improved BP control, less confusion, etc. Improved medication use
Dennee Frey, PharmD WHAT’S IT ALL ABOUT?
Evidence-Based Origins • Vanderbilt University – John A. Hartford Foundation Funds – RCT proved efficacy in home health – Based on a pharmacist-nurse collaboration to identify & resolve errors – Results: • 19% had potential medication problems • Medication use improved in 50% of patients, (compared to 38% of controls) when pharmacist collaborated with home health staff
HomeMeds: Further Evidence AoA Funds and USC Evaluation • In Medicaid Waiver for Dual Eligibles (nursing-home eligible, living at home) – Social workers & nurses collected data • Results¹,²: 49% had potential medication problems – After pharmacist review 29% of all waiver clients required physician intervention • Medication use improved in 61% of clients 1 Prevalence of Potential Medication Problems in Dually-Eligible Older Adults in Medicaid Waiver Services. Alkema GE, Wilber KW, Enguidanos SM and Frey D. The Annals of Pharmacotherapy . December 2007, Volume 41. 2 The Role of Consultant Pharmacists in Reducing Medication Problems Among Older Adults Receiving Medicaid Waiver Services. Alkema G, Enguidanos S, Wilber K, Trufasiu M and Frey D. The Consultant Pharmacist . Feb-2009, V.24, No. 2.
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)
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 1. Unnecessary therapeutic duplication 2. Use of psychotropic drugs in patients with a reported recent fall and/or confusion 3. Use of non-steroidal anti-inflammatory drugs ( NSAID ) in patients at risk of peptic ulcer/ gastrointestinal bleeding . 4. 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.
Fidelity to Core Components • Comprehensive medication inventory & assessment • Collect data on falls, dizziness, confusion, vitals • Risk screening per protocols • Review of alerts & clinical signs by a pharmacist • Written recommendations from pharmacist to prescribers • Follow through with MD and/or client/family • Documentation of all actions and results
HomeMeds Intervention Process
“We’re not a medical program…” “…but you’re in the home” • Already visit home and collect medication and other assessment information • Coordination & communication role • Trust of clients • Focused on delaying institutionalization • Funding – Title III-D & Waiver purchase of service
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 • Avg. 30 min./client
Case presentation A 76 year old woman with several chronic conditions recently admitted to waiver program reported taking six medications and experiencing dizziness over the past several months. Screening: 2 alerts: therapeutic duplication and dizziness 2 beta blockers: atenolol 50 mg and metoprolol 100 mg Pharmacist Review/consultation: recommended that the case manager verify that the client was taking both beta blockers regularly. Confirmation: RN/CM confirmed the duplication and contacted the primary care physician to report the duplication and medication-related dizziness, and requested one of the beta- blockers be discontinued. Follow-up: The care manager then followed-up with the client to assure the MD orders were carried out and that the client understood how to take her medications correctly
HOMEMEDS: BRINGING IT HOME WITH STORIES OF SUCCESS
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!”
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