Detecting

1
Detecting Improving Medication Use Among
Vulnerable EldersA Community-Based Medication
Management Intervention

• Gretchen Alkema
• VA Greater Los Angeles Healthcare System
• Kathleen Wilber
• USC Andrus Gerontology Center
• June Simmons, Sandy Atkins, Mira Trufasiu,
  Dennee Frey
• Partners in Care Foundation
• Gerontological Society of America Meeting
• November 19, 2007

2
Acknowledgements

• Collaborators
• USC Andrus Gerontology Center
• Kathleen Wilber, PhD
• Partners in Care Foundation
• Dennee Frey, PharmD
• June Simmons, CEO/LCSW
• Mira Trufasiu, MSG
• Sandy Atkins, MPA
• Susan Enguidanos, PhD
• Huntington Hospital Senior Care Network
• Eileen Koons, LCSW
• Lois 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)

3
Problem of Medication Errors

• 65 12 of population but consume ? 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

4
Evidence-Based Practice (EBP)in a New Setting

• Implemented tested medication management
  protocols from
• Medicare home healthcare RCT
• to
• Medi-Cal waiver care management

5
(No Transcript)
6
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

7
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

8
Care Management Sample (N615)
Site 1 n216
Site 3 n126
Site 2 n273
9
Targeted Medication Problems (Brown et al., 1998,
Meredith et al., 2001)

• Unnecessary therapeutic duplication
• Psychotropic drug use w/ confusion or falls
• Cardiovascular medication problems
• Use of non-steroidal anti-inflammatory drugs
  (NSAIDs) with peptic ulcer risk

10
Research Design

11
Research Design

12
Research Design
13
Care Management Sample (N615)

• 81 years old
• 80 female
• 53 widows
• 40 lived alone
• 36 new to care management

Photo by Rollin Riggs, NY Times
14
Race/Ethnicity by Site (N615)
15
Language Preference (N615)
16
Health Status (N615)

• Mean of meds 8.76 (SD4.3) 12 meds 22
• 38 ED, Hospital, or SNF in previous year
• 22 falls in previous 3 months
• 27 dizziness
• 31 confusion

17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
(No Transcript)
22
Attrition

• 10 left before med problems confirmed
• ? fallers (p
• 100 w/ 1 potential problem (p
• 19 left before intervention completed
• ? of meds (p
• Main reasons LTC, died, or moved

23
Prevalence Results (N615)
24
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

25
Problems by Meds
26
Intervention Results (N162)
27
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 doctorsome 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

28
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

29
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

30
Photo by JL Forter