Medication Management Support Services (MMSS) Aging at Home Mary - - PowerPoint PPT Presentation

Medication Management Support Services (MMSS) Aging at Home

Mary Burello-Cordovado Senior Manager, Client Services, Special Projects

March 3, 2010

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Objectives

• Update on Medication Management Support

Services (MMSS) as an Aging at Home Strategy

• Provide an overview of the project and case

examples of success

• How does MMSS keeps older adults healthy at

home?

• Review outcomes and demonstrate quality

measures to date

• Demonstrate how MMSS can reduce potential ED

visits

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Background

• In June 2008, the Central LHIN approved the Medication

Management Support Services (MMSS) project.

• The organizations involved:
• Central CCAC – Project Lead
• SRT Med Staff
• COTA Health now VHA Rehab Services
• York Central Hospital
• Southlake Regional Health Centre
• New members:
• St. Elizabeth Health Care
• Acute care hospitals in Central LHIN

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Central CCAC York Central hospital VHA Rehab SRT Med Staff Inc. St. Elizabeth Health Care Hospitals Client/ Caregiver Community Pharmacist Physicians

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Seniors + Medications = ER visits? Seniors + Medications = ER visits?

ADEs account for an estimated 10-17% of admissions to hospital involving elderly patients (Hayes et al, 2007), and it has been suggested that as many as 75% of these admissions could have been prevented if medications had been used appropriately (reviewed in Gallagher et al, 2007)

Adapted from Polypharmacy in the Frail Elderly (GiiC)

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High Risk Issues

• Canadian Study (CMAJ June 3, 2008 – ZED PJ et al)
• 122 patients had medication-related admissions
• 83 of these were deemed preventable*

Most Com m on Medication Problem Adverse Drug Reaction 39.3% Non-adherence 27.9% * Improper Dose 12.3% Improper Drug Selection 11.4% Untreated Indication 9.0%

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Value Stream Analysis: August 2008

• 3-day event with:
• Project Partners
• ISMP was in attendance as well as a representative from the

Pharmacy Association

• Staff from prior Scarborough CCAC project
• Identified that existing processes show duplication of effort
• Too many lists completed and not shared
• Meds Check not well-known
• Central CCAC clients would benefit from medication

reconciliation

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What is the Eligibility Criteria?

• Mandatory Criteria
• 65 years or older
• Taking three (3) or more medications
• Has one (1) or more chronic diseases
• Valid OHIP; eligible for CCAC services
• Resident of Central CCAC
• One or more risks as identified in eligibility criteria (falls,

frequent visits to ER/ hospitalizations, uncontrolled pain)

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Medication Management Support Services

• Phase 1: MMSS1 – Nursing
• 2 visits in 30 day period
• Phase 2: MMSS2 – Pharmacy
• 2 visits in 30 day period
• CCAC Case Manager/ Service Provider can recommend

Phase 1 or Phase 2 of MMSS depending on complexity of client

• Clients in Phase 1 can be referred to Phase 2 by the

nurse provider or CCAC

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How have the clients benefited?

• Enables nurse and pharmacist to:
• Create a complete and accurate inventory of all

medications

• Prescribed/ over-the-counter/ herbal
• Review storage and organization of medications
• Assess the appropriateness of medications
• Assess client/ caregiver self-administration/ caregiver skill

and methods

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How have the clients benefited?

• Determine any cognitive deficits which would prevent

the client/ caregiver from safely administering medication

• Determine any physical deficits which impede

client/ caregiver ability to administer the prescribed medication

• Reduced vision, decrease in manual dexterity
• Compare the current medications with medications

prescribed

• Identify any discrepancies/ medication related problems
• Bring it to the attention of the prescribing physician

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What can the client expect?

• The nurse or pharmacist completes and provides a medication

schedule

• After confirmation and discrepancies are resolved with the prescribing

physician

• Makes recommendations
• The need for aides or cues
• Blister pack/ Compliance packaging or dosette system, visual

reminders

• Make recommendations
• Additional or increased services
• Increased PSW hours for reminders, OT assessment, referral to a

community support agency, nursing visits

• Educate the client/ caregiver regarding medications, side-effects,

dose, administration times, and procurement of medications

• Storage
• Copy of the schedule is then sent to the family physician

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Medication Management Support Services

“W here Principles of Pharm acy

Practice Converge”

Albert Chaiet, R.Ph., B.Sc.Phm., M.Sc.Phm., M.B.A. Director, Pharmacy Services, York Central Hospital

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Convergence

• Standards of Practice
• Pharmaceutical Care
• Medication Reconciliation
• CSHP 2015

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Standards of Practice

• Ontario College of Pharmacists
• Canadian Society of Hospital Pharmacists

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Pharmaceutical Care

• Identifying and resolving potential or actual drug

related problems

• Care planning
• Ethics of care
• Duty of care

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Medication Reconciliation

• Accreditation Canada R.O.P.s
• BPMH on admission
• Reconciliation at transfer points including

discharge

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C.S.H.P. 2015: Goal 2

• “Increase the extent to which pharmacists help individual

non-hospitalized patients achieve the best use of medications”

• Objective 2.3:

In 85% of home care services, pharmacists will manage medication therapy for patients with complex and high-risk medication regimens, in collaboration with other members

• f the healthcare team”

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A Pharmacist Home Visit A Pharmacist Home Visit … … … …

• Can unlock the door to the problem
• We can see exactly what the patient has at home

(contrary to a list!)

• Patient is comfortable in their surroundings
• Minimal distractions
• Environment scan to see how managing the

medications

• Pharmacists are very skilled at dealing with

medication issues

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Identifying limitations Identifying limitations

• Physical
• Cognitive
• Accessibility
• Adherence
• Safety
• Knowledge
• Storage and Organization

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Interventions for Disease Prevention or Interventions for Disease Prevention or Management Management

• Indications are appropriately treated
• Preventative medicine is used and Rx’d

appropriately (e.g. Vitamin D, EC ASA)

• Administration techniques appropriate
• Disease exacerbation – knows the plan
• When to use Nitroglycerin Spray
• SOB – what puffer to have handy
• Uncontrolled B.S. when sick

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Medication Management Visit Means: Medication Management Visit Means:

• Asking the patient for their desired goals from

their medication

• Educating
• Acting as an advocate for the patient
• Recommending professional services to benefit

the patient

Assess all com ponents of their m edications for:

Safety, Simplicity and Correctness

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Case Case Discharge from Hospital Discharge from Hospital

• Direct referral to pharmacy

Direct referral to pharmacy

• Client on blister pack system

Client on blister pack system

• Blister pack filled according to D/ C

Blister pack filled according to D/ C rx rx

• Community

Community phm phm contacted hospital MD regarding contacted hospital MD regarding insulin insulin – – not on Rx not on Rx

• Instructed to tell client to

Instructed to tell client to f/ u f/ u with family MD with family MD

• Client to see family MD in 5 days

Client to see family MD in 5 days

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Pharmacist Home Visit Pharmacist Home Visit

• Had medication reconciliation form, labs and copy of D/ C

Had medication reconciliation form, labs and copy of D/ C rx rx from hospital records from hospital records

• First question they asked

First question they asked – – “ “ What about her insulin? What about her insulin?” ”

• Hospital increased oral BS meds to control DM

Hospital increased oral BS meds to control DM – – not not knowing she used insulin at home knowing she used insulin at home

• Family MD appt in 5 days. Been on oral regimen for last 3

Family MD appt in 5 days. Been on oral regimen for last 3 weeks in hospital B.S. not too bad (assess urgency) weeks in hospital B.S. not too bad (assess urgency)

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Pharmacist Home Visit Pharmacist Home Visit

• Reviewed blister pack

Reviewed blister pack – – rx rx’ ’s s all correct from all correct from discharge Rx discharge Rx

• Iron being given at breakfast (interacts with her

Iron being given at breakfast (interacts with her levothyroxine levothyroxine) and bedtime ) and bedtime

• + + heartburn and upset stomach

+ + heartburn and upset stomach – – PPI switched PPI switched at time of discharge, at time of discharge, Metformin Metformin or Ferrous

• r Ferrous

gluconate gluconate could be contributing could be contributing

• c/ o tingling in fingers

c/ o tingling in fingers

• Community

Community phm phm helped chg helped chg Pariet Pariet to her normal to her normal PPI of PPI of Prevacid Prevacid and and chg chg’ ’d d timing of iron timing of iron

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Pharmacist Home Visit Pharmacist Home Visit

• BP meds had been decreased in

BP meds had been decreased in hospital hospital – – checked BP 147/ 68 during checked BP 147/ 68 during visit visit

• Neuropathy meds had been

Neuropathy meds had been d/ c d/ c’ ’d d in in hospital with no replacement hospital with no replacement

• Upset stomach and heartburn

Upset stomach and heartburn

• Encouraged BS monitoring 3

Encouraged BS monitoring 3-

• 4

4 times a day from now until MD appt times a day from now until MD appt

• + + reassurance to family and client to

+ + reassurance to family and client to continue as planned continue as planned

• Issues faxed to Family MD

Issues faxed to Family MD

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Follow Follow-

• up

up

• MD faxed back interventions

MD faxed back interventions

• Contacted community pharmacy to implement

Contacted community pharmacy to implement with next blister pack ( with next blister pack ( d/ c d/ c most oral BS meds, most oral BS meds, restart insulin, increase BP med) restart insulin, increase BP med)

• Follow

Follow-

• up appointment booked day of restarting

up appointment booked day of restarting insulin (had to coincide with new blister pack insulin (had to coincide with new blister pack start date) start date)

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Follow Follow-

• up Visit

up Visit

• Met with client, husband and friend to translate

Met with client, husband and friend to translate (daughter contacted via telephone) (daughter contacted via telephone)

• Reviewed new blister pack

Reviewed new blister pack

• Client major complaint still + + + heartburn and

Client major complaint still + + + heartburn and burping (despite MD doubling dose of burping (despite MD doubling dose of Prevacid Prevacid a a week ago) week ago)

• Received MD order to hold lunch dose of iron

Received MD order to hold lunch dose of iron (could be aggravating) and trial of (could be aggravating) and trial of Domperidone Domperidone (diabetic (diabetic gastroparesis gastroparesis) )

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Follow Follow-

• up Visit

up Visit

• Asked client to show me her

Asked client to show me her insulin pen insulin pen – – had previously had previously viewed insulin cartridges on viewed insulin cartridges on first visit first visit

• Client has no insulin pen!

Client has no insulin pen! Draws up from that tiny hole in Draws up from that tiny hole in the insulin cartridge the insulin cartridge

• Contacted community

Contacted community pharmacist pharmacist – – they had no idea they had no idea either either – – ordered a pen

• rdered a pen
• W/ E community

W/ E community phm phm delivered delivered blister pack and taught how to blister pack and taught how to use pen use pen

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Quality Measures

• Focus on three areas:
• Individual Health Experience
• Population Health
• Cost Savings

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Have we made a difference?

• Qualitatively
• Satisfaction surveys indicate that clients have

found the service to be excellent and would recommend it to their friends and families!

• Family physicians have contacted us to request

that we continue this invaluable service for their patients.

Have we made a difference?

• Over 600 clients referred to the program
• 250 discharged clients
• Discrepancies identified – 930
• Discrepancies resolved – 775 (83% )
• Medication related problems identified – 1051
• Medication related problems resolved – 839 (80% )
• On average a reduction of 1 medication/ client

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Quality Measures cont’d

Cost savings

• $ 17 410 savings in medication to the health care

system for 189 discharged clients

• There was also a reduction in the frequency of visits for

some clients to ED post MMSS

• Further work is required to extrapolate further cost

savings i.e. reduction in hospitalizations

MMSS Clients and ED

MMSS Clients and ED

Respondent Profile

Providers and Rem inders

Negative Reactions to Medications

Satisfaction w ith Medication/ I nform ation

Before and After MMSS

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Before and After MMSS

Before and After MMSS

In Q3 45% of respondents reported an improvement in self- management of medication after having Medication Management Support Services. The remaining 55% reported no change.

Before and After MMSS

Before and After MMSS

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Before and After MMSS

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What Respondents Have to Say About MMSS

• The pharmacist was very professional and caring.
• Pharmacist did an excellent job and would recommend her

to anyone who needed explanations of drugs and when to take them

• Thank you for the help. Pharmacist and case study nurse

provided re: Medication and options including liquid versus solid options for some if needed for swallowing different.

• I think this is a wonderful service and I have benefitted by

the visit.

• It was a relief to confirm what you already knew.
• Very grateful

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What Respondents Have to Say About MMSS cont’d

• This opportunity has given me more confidence in taking medication especially with the
• ver the counter drugs.
• Very helpful and should become a regular service.
• Home visit by pharmacist was very helpful.
• This is a terrific new service for many. Thanks.
• Happy with management services especially nurse and pharmacist coming to home.
• My father has problems with short term memory and requires visits from pharmacist

about every 3 months to review and refresh him on the medication he is taking, otherwise he refuses his meds.

• The service as you can see is excellent. I have informed my doctor of the service, he is very

impressed.

• Before the pharmacist, I did not know the reaction of the vitamins with warfarin.
• The pharmacist also made some good suggestions to change multivitamins and increase

blood pressure medications.

• What a fantastic service. This is very worthwhile and informative.
• Need to know a little more about the purpose of each medication.

An Opportunity We Cannot Afford to Miss:

Meds Check, Medication Reconciliation, Home Care Drug Reviews

Margaret Colquhoun R.Ph., Bsc. Phm ., FCSHP Project Leader I SMP Canada

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Medication Information Transfer in the Community

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Medication Discrepancies in Outpatient Pharmacy Practice

Reference: Reference: Bedell Bedell SE, et al. SE, et al. Arch Intern Med Arch Intern Med 2000; 160: 2129 2000; 160: 2129-

• 2134.

2134.

• Medication discrepancies involved all classes of medications
• E.g. Patients taking medications that were not recorded

(n= 278 [ 51% ] )

• E.g. Patients not taking a recorded medication (n= 158

[ 29% ] )

• Predictors of medication discrepancies in outpatient practice
• I ncreasing age
• I ncreasing num ber of prescribed m edications

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Adverse Events Before Admission

Reference: Forster AJ, et al. Reference: Forster AJ, et al. CMAJ CMAJ 2004; 170(8): 1235 2004; 170(8): 1235-

• 1240.

1240.

• 39 of 64 patients (61% ) experienced the adverse

event before admission

• Cause of adverse events
• Drug treatment
• Operative complications
• Nosocomial infections

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Adverse Events After Discharge

Reference: Forster AJ, et al. Reference: Forster AJ, et al. CMAJ CMAJ 2004; 170(3): 345 2004; 170(3): 345-

• 349.

349.

• 76 of 328 patients (overall incidence 23% )

experienced at least one adverse event after discharge

• Most common adverse events
• Adverse drug events (72% )
• Therapeutic errors (16% )
• Nosocomial infections (11% )

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Ontario 2010 Levers

• Medication reconciliation - required in

hospitals, home care and LTC

• MedsCheck in community practice
• Medication review by a pharmacist in

home care paid by MOHLTC

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Overview of MedsCheck/ Medication Reconciliation Pilot - 2008

To facilitate the linkage of the MedsCheck program in community pharmacies with the medication reconciliation process in hospitals across Ontario.

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Pilot Objectives

To I m prove :

• Com m unication of medication information
• Continuity of care for the patient/ client at

transitions of care.

• Accuracy of medication ordering
• Efficiency by reducing re-work

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Pilot Results

• 113 MedsChecks collected
• 180 discrepancies were identified between

the BPMH and the MedsCheck

• Average of 1.6 discrepancies per

MedsCheck

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Types of Discrepancies

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Pilot Implications

Requires:

• Reliable quality of MedsCheck (BPMH training)
• Staff and physician buy-in (hospital change

management)

• Coordination and planning across interfaces of

care

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CSHP Ontario Branch ISMP Canada Roundtable (sponsored by Pfizer)

• Design and implement a multidisciplinary invitational

roundtable to focus on optimizing medication reconciliation and communication at transitions in care

• Design systems to further support community and hospital

pharmacists’ participation in Linking MedsCheck to MedRec across Ontario

• Prepare and disseminate a report with recommendations for

solutions

• Facilitate the implementation of solutions identified at the

roundtable

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Next Steps

• CSHP OB and I SMP Canada invitational

sym posium

• MOHLTC proposal
• Create system that w orks in 1 -2 LHI N’s

and involving hom ecare

• I ncrease hospital m edication reconciliation

at discharge – I SMP Canada / SHN

• I m prove frequency and quality of MedsCheck

– BPMH training

Lessons Learned for MMSS

• Data not always easy to pull or

understand-don’t give up!

• Test and retest processes until you get

it right.

• Excellent Senior leaders supportive

and removed barriers as required.

• Collaboration and relationship

building- better way to deliver service.

• Always keep the client/ patient central

to keep everyone focused on the goal.

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Questions?

Mary Burello mary.burello@central.ccac-ont.ca Lisa Sever lsever@yorkcentral.on.ca Marg Colquhoun MColquhoun@ismp-canada.org