Introduction to the Oral Medication Management Statewide Initiative

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Introduction to the Oral Medication Management
Statewide Initiative

• March 14, 2006

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Objectives

• Review the components of the management of oral
  medications quality measure
• Review the Oral Medication Management Improvement
  Matrix its application to Plan of Action
  Development
• Discuss the Oral Medication Management Planning
  Packet
• Discuss application of the OBQI process
  identify strategies to improve this outcome
• Identify resources to support agency performance
  improvement efforts

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Historical Perspective Oral Medication
Management Quality Measure Rates

• Launch of Home Health Compare (11/2003)
• National Average 35
• NYS Average 38
• Most Recent Update of Home Health Compare
  (12/2005)
• National Average 40
• NYS Average 42
• CMS 8th Scope of Work Goal (2008) 90

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OASIS Item M0780 (Source OASIS Implementation
Manual Chapter 8 12/02

• (M0780) Management of Oral Medications
• Patients ability to prepare and take all
  prescribed oral medications reliably and safely,
  including administration of the correct dosage at
  the appropriate times/intervals.
• Excludes injectable IV medications.
• (NOTE This refers to ability, not compliance or
  willingness.)

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OASIS Item M0780(Source OASIS Implementation
Manual Chapter 8 12/02
Prior Current ? ? 0 Able to independently take the correct oral medication(s) proper dosage(s) at the correct times.
? ? 1 Able to take medication(s) at the correct times if (a) individual dosages are prepared in advance by another person OR (b) given daily reminders OR (c) Someone develops a drug diary or chart.
? ? 2 Unable to take medication unless administered by someone else.
? ? NA No oral medications prescribed.
? ? UK Unknown
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OASIS Item M0780 (Source OASIS Implementation
Manual Chapter 8 12/02)

• Prior column should describe the patients
  ability 14 days prior to the SOC (or resumption)
  of care visit.
• Current column should describe what the patient
  is ABLE to do today.

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OASIS Item M0780(Source OASIS Implementation
Manual Chapter 8 12/02)

• Unknown is an option only in the prior column
• Only medications whose route of administration
• is PO should be considered for this item
• Medications given per gastrostomy (or other) tube
  are not administered PO, but are administered
  per tube.

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Calculation of Outcome Rates

• OASIS data from SOC/ROC AND discharge/transfer
  during the specified 12-month time period
• Numerator all episodes that had the outcome
  (potential to improve)
• Denominator all eligible episodes
• Optimal status at SOC / ROC is excluded (NOT a
  0 for MO780)

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OBQI Plan of Action Development

• How can we improve our patients ability to
  manage their oral medications over the course of
  the home care episode?
• Utilize agency clinical staff to identify
  clinical activities / actions that might improve
  ability to manage oral medications
• Assessment
• Clinical interventions/teaching
• Care planning/coordination

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Oral Medication Management Planning Packet

• Oral Medication Management Improvement Matrix on
  CD ROM
• Oral Medication Management Tools Resources on
  CD ROM
• Process of Care Investigation Clinical Record
  Audit Tool
• Plan of Action Template

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Oral Medication Management Planning Packet

• Instructions for navigation through the Patient
  Tally Workbook on the CD ROM incorporated into
  the Acute Care Hospitalization Planning Packet
  forwarded in October.
• A hard copy of sample intervention strategies
• A resource guide of best practice tools including
  a medication assessment protocol, staff
  educational tools addressing medication
  non-adherence, teaching strategies, the
  Medication Simplification Protocol, Beers
  Criteria, medication compliance aids, care
  planning tools and a patient educational tool for
  medication management.

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Oral Medication Management Improvement Matrix
Tools Resources
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Improvement MatrixAreas for Improvement

• Promoting Patient Self-Management
• Implementing Evidence-Based Practices
  Guidelines
• Using Systems and Technology to Promote
  Effectiveness and Efficiency
• Improving Care Delivery Systems Mobilizing
  Community Resources
• Creating a Culture of Quality

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Oral Medication Management Improvement Matrix
Definitions

• Change Framework entire set of change concepts
  organized into Areas for Improvement and Stages
  of Care
• Improvement Matrix big picture of the
  organization and high-level strategies
• Strategy high-level change concept represents
  a series of actions designed to achieve a
  specific objective
• Action specific change idea that can be tested
  and implemented at the agency level
• Tool a form, instrument, or manual that can be
  used as is or modified to support strategies and
  actions
• Resource a reference for more information
  related to implementing specific strategies and
  actions

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Strategy Example Using Systems Technology to
Promote Effectiveness Efficiency

• Strategy C.2 Use systems to enhance effective
  internal and external communication and
  continuity of care
• - Staff communication within and
  between disciplines (including
  paraprofessionals), between office-based
  and frontline staff
• - Communication with key physicians
• - Communication with patients/families

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Strategy C.2 Actions, Tools, Resources
Rationale
Actions Tools Resources Rationale
C.2.1 Review medication profile to identify opportunities to simplify medication regimen Encourage use of single pharmacy Coordinate with pharmacy on customized medication packaging based on patient need Collaborate with key physicians Medication Simplification Protocol (39) Medication Management Model (42) Best Practice Tools Talking with Physicians Related to Medication Simplification (43) Beers Criteria (44) Simplifying the medication regimen increases adherence. Adherence has been found to be inversely proportional to the frequency of doses. Decreasing use of inappropriate medications will minimize medication related problems. Efficient, effective and standardized communication processes between the home care provider physician can enhance collaborative efforts.
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Application of the Improvement Matrix to OBQI
Process
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OBQI Outcome Enhancement Process
Collect transmitOASIS data
Measurepatientoutcomes
Monitoractionplan
Interpretoutcomereports
Implementaction plan
Specifytargetrate
Developaction plan
Investigatecareprocesses
Identifyproblems/strengthsand best practices
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OBQI and the Improvement Matrix

• Where how to start key issue
• Comprehensive Change Framework
• Represents excellent system of care required to
  make transformational change
• Not intended to do everything
• Add strategies over time
• Issues not the same in every agency
• The OBQI process with some additional diagnostic
  tools can help narrow the focus

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Next Steps for Plan of Action Development

• Interpret Outcome Reports Specify
• Target Rate for Agency
• Major Component of Plan of Action development
• Compare agency risk-adjusted rate to other
  agencies in state other benchmarks
• Expectations for reductions should be based on
  agencys baseline rate (Agency Trend Report)
• Average rate is not necessarily the goal

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Next Steps for Plan of Action Development

• Conduct Process of Care Investigation
• Utilize the ACH chart audit tool or clinician
  interview guide
• Randomly select up to 30 patient care episodes
• Review the care episodes
• Summarize findings

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Patient Tally Report Workbook

• Excel-based tool
• Contains raw OASIS data for all of the patients
  included within your OBQI report
• Combines your Case Mix Tally and Outcome Tally
  Reports into one tool
• Allows you to query your OASIS data to determine
  case mix patient outcome information

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Patient Tally Report Workbook

• Open up Patient Tally Workbook
• Select second option on menu Create New Query
  on Existing Spreadsheet Data
• Follow Patient Tally Report Instructions provided
  in Oral Medication Planning Packet to create
  query of patients who both achieved did not
  achieve improvement in oral medication management

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Patient Tally Report Workbook

• Select 30 patients to perform a record review
  utilizing the Audit Tool included in the Oral
  Medication Planning Packet

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Oral Medication Management Clinical Record Review
Tool
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Agency Decisions

• Determine the review format
• Determine who will conduct the review
• Determine the cases to be reviewed
• Determine the review time frame

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Pitfalls to Avoid During Process of Care
Investigation

• Premature closure (jumping to conclusions)
• Involving only agency management
• Blaming data collection or analysis methods
• Not focusing on care delivery

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Drawing Conclusions

• Compile team member tally sheets
• Aggregate results
• Summarize problem area(s)

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Develop Problem Statement(s)

• Describes specific aspect(s) of care that
  demonstrate opportunities to improve care
• Contains specific, concrete wording to which
  clinical staff can relate
• Addresses issues within the agencys control
• Focuses on patient care delivery instead of
  documentation
• Contains a sufficiently narrow focus to keep a
  plan of action manageable

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Identify Best Practices

• Identify the problem or strength
• Specific strategies from the Improvement Matrix
  can be considered for clinical best practices,
  especially those from
• Promoting patient self-management
• Implementing evidence-based practices and
  guidelines

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Considerations for Action Plan Development

• Staff Interpretation of OASIS Question Response
  Selection
• Multidisciplinary involvement to address oral med
  management
• PT, OT, ST, Social Work, HHA Pharmacist
• Reference tools for staff guidance
  communication
• Beers Criteria
• Medication Assessment Protocol
• Medication Simplification Protocol
• Educational tools addressing medication
  non-adherence
• Teaching strategies
• Medication compliance aids care planning tools
• Patient educational tools for medication
  management

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Considerations for Action Plan Development

• Medication Reconciliation
• Organize an interdisciplinary team to
  develop/review policies for medication management
• Ensure a list of patients current medications is
  received at time of referral
• Develop a standardized trigger tool/interview
  guide to assist staff in obtaining all medication
  information
• Provide education to therapists nurses on
  medication reconciliation
• Thoroughly assess medication history by
  examining all medication vials in home (including
  OTC containers)
• Reconcile medications at all transition points
  during the patients episode (post ED, recert,
  post MD appt)
• Source Ketchum, K., Grass, C. A., Padwojski, A.
  (2005). Medication reconciliation. American
  Journal of Nursing, 105 (11), 78-85

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Intervention Actions

• What is to be Done
• When it is to be Done
• Who is Responsible
• How Action is to Monitored

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Implement the Action Plan

• Clinical staff informed
• Responsible persons carry out intervention
  activities
• Specified activities occur as planned

39
Monitor the Action Plan

• POA is a dynamic tool
• Emphasize small test of change before full-scale
  implementation
• Monitor
• Intervention actions occurred
• Best practices are used consistently
• Outcome

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Tips for Internal Monitoring

• Monitor your measures over time
• Assign responsibilities for data collection
• Utilize all staff levels for record review
• Establish a schedule and process for data
  collection
• Consider real-time data collection
• Integrate data collection into ongoing work

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Next Steps

• Discuss with Team
• Further investigation?
• Finalize POA
• Implement POA
• Conduct Small Tests of Change
• Measure Monitor
• Work Collaboratively with IPRO and other HHAs

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Goals

• Submit Oral Medication Management Plan of Action
  to IPRO no later than 05/01/06, for review and
  comment

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Website Resources

• MedQIC Website www.medqic.org
• IPRO www.ipro.org
• Joint Effort New York (JENY) Website -
  http//jeny.ipro.org
• Home Health Compare - www.medicare.gov/hhcompare/h
  ome.asp

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Contact Information

• Sara Butterfield , RN, BSN, CPHQ, CCM / Project
  Director
• Phone [phone] ext. 104
• Email sbutterfield_at_nyqio.sdps.org
• Christine Stegel RN, MS, CPHQ /Performance
  Improvement Coordinator
• Phone [phone] ext. 113
• Email cstegel_at_nyqio.sdps.org
• Susan Hollander MPH, CPHQ / Assistant Director
• Phone [phone] ext. 241
• Email shollander_at_nyqio.sdps.org

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