Improving Medication Management in ALFs: A Pharmacist’s ... · 10/16/2008 · Rhoads M, Thai...
Transcript of Improving Medication Management in ALFs: A Pharmacist’s ... · 10/16/2008 · Rhoads M, Thai...
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ImprovingMedicationManagementinALFs:APharmacist’sPerspective
NicoleBrandt,PharmD
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MedicationManagementinALFs
• MedicationmanagementisonepotentialIADLthataresidentmayreceiveassistancewith– Approximately85%ofresidentsgethelpwiththeirmedications
Losben NL. Medication management programs: A safe investment. Assisted Living Consult. January/February 2005.23-25.
Assisted Living Federation of America (ALFA). 2006 Overview of Assisted Living Facts & Trends. Alexandria, VA:ALFA;2006
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• SinceALF’sareregulatedbythestateratherthanfederalgovernment,variationsofregulationsexist
• In2003,theAssistedLivingWorkgroupcreatedalistofrecommendedpoliciesconcerningmedicationmanagementinALF’s
Losben NL. Medication management programs: A safe investment. Assisted Living Consult. January/February 2005.23-25.
Assisted Living Federation of America (ALFA). 2006 Overview of Assisted Living Facts & Trends. Alexandria, VA:ALFA;2006
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RecommendedPoliciesforMedicationManagement
• Medicationorders,includingtelephoneorders
• Pharmacyservices
• Medicationpackaging
• Medicationorderingandreceipt
• Medicationstorage
• Losben NL. Medication management programs: A safe investment. Assisted Living Consult. January/February 2005.23-25.
• Assisted Living Federation of America (ALFA). 2006 Overview of Assisted Living Facts & Trends. Alexandria, VA:ALFA;2006
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RecommendedPolicies,cont’d.
• Disposalofmedicationsandmedication‐relatedequipment
• Medicationself–administrationbytheresident
• Medicationreminders
• Medicationadministration
Losben NL. Medication management programs: A safe investment. Assisted Living Consult. January/February 2005.23-25.
Assisted Living Federation of America (ALFA). 2006 Overview of Assisted Living Facts & Trends. Alexandria, VA:ALFA;2006
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RecommendedPolicies,cont’d.
• Medicationadministration–specificprocedures
• Documentationofmedicationadministration
• Medicationerrordetectionandreporting
Losben NL. Medication management programs: A safe investment. Assisted Living Consult. January/February 2005.23-25.
Assisted Living Federation of America (ALFA). 2006 Overview of Assisted Living Facts & Trends. Alexandria, VA:ALFA;2006
Losben NL. Medication management programs: A safe investment. Assisted Living Consult. January/February 2005.23-25.
Assisted Living Federation of America (ALFA). 2006 Overview of Assisted Living Facts & Trends. Alexandria, VA:ALFA;2006
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RecommendedPolicies,cont’d.
• Qualityimprovementsystem,includingmedicationpreventionandreduction
• Medicationmonitoringandreportingofadversedrugeffectstotheprescriber
LosbenNL.Medicationmanagementprograms:Asafeinvestment.AssistedLivingConsult.January/February2005.23‐25.
AssistedLivingFederationofAmerica(ALFA).2006OverviewofAssistedLivingFacts&Trends.Alexandria,VA:ALFA;2006
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Recommendedpolicies,cont’d.
• Reviewofmedication
• Storageandaccountabilityofcontrolleddrugs
• Training,qualificationsandsupervisionofstaffinvolvedinmedicationmanagement
• Losben NL. Medication management programs: A safe investment. Assisted Living Consult. January/February 2005.23-25.
Assisted Living Federation of America (ALFA). 2006 Overview of Assisted Living Facts & Trends. Alexandria, VA:ALFA;2006
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ImportanceofMedicationManagementinAssistedLiving
• Thepurposeoftherecommendedpoliciesweretohelpfacilitiescreateamedicationmanagementservicethatwouldworkeffectivelyandprovidecorrectmedicationtotheresidents.
AssistedLivingWorkgroupReporttotheU.S.SenateSpecialCommitteeonAging.TopicGroupRecommendationsAdoptedbyTwo‐ThirdsMajorityoftheALW.April2003
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• Thestaffofferingadministrationorassistancewouldbeknowledgeableaboutthemedication
• Residentsthatneededhelpwiththeirmedicationwouldgetthecorrectdrugs
• Areviewofthemedicationswoulddecreasepotentiallyharmfulinteractionsoreffectsaswellaslowercosts
• AssistedLivingWorkgroupReporttotheU.S.SenateSpecialCommitteeonAging.TopicGroupRecommendationsAdoptedbyTwo‐ThirdsMajorityoftheALW.April2003
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OngoingMedicationManagementChallenges….
• In2008,5yearslater,aMedicationManagementSymposiumnotedthat:
• Balancingconsumersafetyandautonomywithselfadministrationisongoing
• LackoftrainedhealthcareprofessionalsspecializingingeriatricscaringforresidentsinALFs
Report from an Expert Symposium on Medication Management in Assisted Living
accessed http://www.assistedlivingconsult.com/issues/04-04/alc78-White%20Paper-728b.pdf on October 16, 2008.
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Challenges,cont’d.
• Lackofuniformityinstateregulationsregardingmedicationmanagement,administrationandassistance
• Littletrainingisofferedtounlicensedassistivepersonnelwhoadministermedications
ReportfromanExpertSymposiumonMedicationManagementinAssistedLiving
accessedhttp://www.assistedlivingconsult.com/issues/04‐04/alc78‐White%20Paper‐728b.pdfonOctober16,2008.
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WhathaveweseeninALFs?
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IncreasingNumbersofMedicationsUsed
• Astudyfrom2001focusingon608residentslivingin109assistedlivingfacilitiesfound:
• Residentsreceivedanaverageof6.2(+/‐3.4)regularlyorderedmedications
Armstrong EP, Rhoads M, Meiling F. Medication usage patterns in assisted living facilities. The Consultant Pharmacist. 2001;16(1).
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• Morethanhalf(58.4%)ofthesemedicationsconsistedofcardiovascular,CNSornutritionalmedications
• Thehighnumberofroutineprescriptionscouldleadtopotentialdrugrelatedproblemsthatcouldbeavoidedifaconsultantpharmacistperformedamedicationreview
• Armstrong EP, Rhoads M, Meiling F. Medication usage patterns in assisted living facilities. The Consultant Pharmacist.2001;16(1).
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InappropriateMedicationUse
• Astudyfrom2003focusingon456residentsfrom124differentassistedlivingfacilitiesfound:
• 144residentshadoneormorepossibleinappropriateroutineorasneededprescriptionsaccordingtoBeer’scriteriaforatotalof204inappropriateorders
Rhoads M, Thai Amy. Physician acceptance rate of pharmacist recommendations to reduce use of potentially inappropriate medications in the assistedliving setting. The Consultant Pharmacist. 2003;18(3).
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• 64ordersweredeterminedtohavearatingofhighseverity
• Oxybutyninandpropoxyphenewerethetwomostfrequentlyprescribeddrugsthatcouldbeinappropriate
• Consultantpharmacyservicesresultedin16.7%ofthepotentiallyinappropriateordersbeingstoppedand2.5%oftheordersreceivingdosechanges(lower)
• Rhoads M, Thai Amy. Physician acceptance rate of pharmacist recommendations to reduce use of potentially inappropriatemedications in the assisted living setting. The Consultant Pharmacist. 2003;18(3).
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HowdoesthisimpacttheresidentsinALFs?
• Amongtheelderly,28%ofhospitalizationsareduetomedicationadverseeventsormedicationnon‐adherence
• Oneoutofeveryfournursinghomeadmissionsisattributedtomedicationmis‐management
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• Adversedrugeventshavebeenreportedasthe4thleadingcauseofdeathamongseniorsandareestimatedtocost$177.4billiondollarseachyear
• Medicationmisuseisparticularlyhighfollowinghospitalization,andevenmoresowhenmultiplechangesaremadetoolderpatient’sregimen
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• Eachyeartherearemorethan180,000potentiallyfatalorfataladversedrugeventsamongMedicarerecipients.– 50%oftheseadverseeventscouldhavebeenprevented
• Medication‐relatedproblemsduetoinappropriateprescribinghasbeendeemedoneofthemostimportantquality‐of‐careissuesforelderlypatients.Forovertwodecades.
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Citationsforpreviousthreeslides
• NanadaC,FanaleJE,KronholmP.Theroleofmedicationcomplianceandadversedrugreactionsinhospitalizationsoftheelderly.ArchInternMed1990;150:841‐5.
• BergJS,et.al.Medicationcompliance:ahealthcareproblem.AnnPharmacother1993;27(suppl):S5‐S19.
• LazarouJet.al.Incidenceofadversedrugreactionsinhospitalizedpatients.JAMA1993;279:1200‐5.
• CurtisLH,OstbyeT,SenderskyV,et.al.InappropriateprescribingforelderlyAmericansinalargeoutpatientpopulation.ArchIntMed2004;164(15):1621‐5.
• ForsterAJ,et.al.Theincidenceandseverityofadverseeventsaffectingpatientsafterdischargefromthehospital.AnnInternMed2003;138:161‐7;BeersMH,et.al.Influenceofhospitalizationondrugtherapyintheelderly.JAmGeriatrSoc1989;37:679‐83.
• GurwitzJH,FieldTS,HarroldLR,et.al.Incidenceandpreventabilityofadversedrugeventsamongolderpersonsintheambulatorysetting.JAMA2003;289:1107‐16
• FinkA.et.al.Assuringqualityofhealthcareforolderpersons.JAMA1987;258:1905‐8.
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PotentialRisksofMedicationsandBenefitsofaPharmacist
1)MedicationRelatedProblems• Oneoutofevery5emergencyroomvisitsare
thoughttobeduetomedicationrelatedproblems
• Theidentificationofmedicationrelatedproblemsbyaconsultantpharmacistmaysavethehealthycaresystemaround$2,250dollarsayearperresidentbypreventingunnecessarytripstotheER
Clark TR. Prevention of medication-related problems in assisted living: role of the consultant pharmacist. ASCP Issue Paper. 2003.
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2)MedicationErrors• Correctimproperdosing,administrationandorders
3)HigherMedicationExpenditures:• Reducetheresident’smedicationcostsbychangingtogenerics,lessexpensivesimilardrugs,orstoppingmedicationsthatarenotnecessary
• Clark TR. Prevention of medication-related problems in assisted living: role of the consultant pharmacist. ASCP Issue Paper.2003.
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WhataresomeofthethingsthataPharmacyandPharmacistcandoto
helpyou?
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1.PerformaMedicationRegimenReview(MRR)
• WhatisMRR?– “Thoroughevaluationofthemedicationregimenofaresident,withthegoalofpromotingpositiveoutcomesandminimizingadverseconsequencesassociatedwithmedications;Thereviewincludespreventing,identifying,reporting,andresolvingmedication‐relatedproblems(MRPs),medicationerrors,orotherirregularitiesandcollaboratingwithothersmembersoftheinterdisciplinaryteam.”
Centers for Medicare and Medicaid Services. State Operations Manutal. Appendix PP: Guidance to Surveyors for Long Term care facilities Rev. 26 Accessed at www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdfwww.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf. on October 16, 2008.
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2.ProvideOngoingEducationtoDirectCareStaff,Residentsand/orthe
Family• Medicationmanagementisbasedinthecareprocessandincludes:– Recognitionoridentificationoftheproblem/need
– Assessment
– Diagnosis/causeidentification
– Management/treatment
– Monitoring
– Revisinginterventions• CentersforMedicareandMedicaidServices.StateOperationsManutal.AppendixPP:GuidancetoSurveyorsforLongTermcare
facilitiesRev.26,Accessedatwww.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdfwww.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf.onOctober16,2008.
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3.AssistwithAssessingResident’sabilitytoSelfAdministerMedications
Variousscreeningandassessmenttoolstoevlauatearesident’sabilitytoselfmedicate.
e.g.,MediCog:evaluatestheabilitytosetupapillbox
TwoPartScreen
Mini‐Cog:detectsclinicallysignificantcognitiveimpairment
MedicationTransferScreen(MTS):evaluatesskillsindecipheringprescriptionsandabilitytosequenceandlocate
CentersforMedicareandMedicaidServices.StateOperationsManutal.AppendixPP:GuidancetoSurveyorsforLongTermcarefacilitiesRev.26• Accessedatwww.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdfwww.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf.onOctober16,2008.
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3.Assessing…con’td.
• Fivetotenminutestoadminister
• RequiresapencilandapreprintedMTSform.
• CentersforMedicareandMedicaidServices.StateOperationsManutal.AppendixPP:GuidancetoSurveyorsforLongTermcarefacilitiesRev.26
• Accessedatwww.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdfwww.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf.onOctober16,2008.
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4.AssistwithPharmaceuticalServices
PharmaceuticalServices”refersto:• Theprocess(includingdocumentation,asapplicable)ofreceivingandinterpretingprescriber’sorders;acquiring,receiving,storing,controlling,reconciling,compounding(e.g.,intravenousantibiotics),dispensing,packaging,labeling,distributing,administering,monitoringresponsesto,usingand/ordisposingofallmedications,biologicals,chemicals(e.g.,povidoneiodine,hydrogenperoxide);
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• Theprovisionofmedication‐relatedinformationtohealthcareprofessionalsandresidents;
• Theprocessofidentifying,evaluatingandaddressingmedication‐relatedissuesincludingthepreventionandreportingofmedicationerrors;and
• Theprovision,monitoringand/ortheuseofmedication‐relateddevices.
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Whatcanbedonetoassuremedicationgetsmanagedappropriately,safelyand
accurately?
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Mythoughts…
• AdvocateforclearerpoliciesandregulationsinALFs
• Hireaconsultantpharmacisttoperformmedicationmanagementreviews
• Ensureongoingevaluationsofmedicationadministration
• Remembertorespecttherightsoftheresident