Using Case Management Interventions to Build a Culture of Medication Adherence in At Risk Older Adults Laura Poust, MSW, LSW, ACM-SW Introduction to the Problem • Ambulatory Care Managers reported that a majority of older adults (65 and older) in their caseloads are on 15 or more medications • Quality Health Alliance coordinates care for over 12,600 Medicare Shared Savings patients (MSSP) (65 and over) • Patients often have difficulty knowing how and when to take medication, especially when their regimens are complex • Three in four American adults, 65 and over, have more than one chronic condition lasting longer than a year • In 2016, approximately 3,220 of injury related hospitalizations in the older adult population in Bucks County were due to unintentional falls, one of the characteristics associated with polypharmacy • By 2060 nearly 24% of the U.S. population is expected to be 65 and older
Program Background • Quality Health Alliance (QHA) Ambulatory Care Managers reported that issues with medication adherence are the highest area of opportunity in the Medicare population, and subsequently created the Enhanced Medication Review Pilot Study •
A blue cooler bag was given to patients and dropped off at provider sites. This included : a pill cutter, pen, a flyer with medication disposal sites in Bucks County, flyer with instruction about the program, and a “my medication” form
• Care Coordination upon agreement to participate in study: • Care Manager contacted patients and schedule their next primary care visit, patient encouraged to bring all medicines in the blue cooler bags • Care Manager attends visit, reviews medication with patient and clinician, and monitor and provide intervention after visit
Goals and Objectives Project Goal Improve medication adherence in the Medicare Shared Savings population by using a modified version of the AHRQ’s Brown Bag Review to build a culture of bringing all medications to provider visits, identify barriers to medication adherence, and minimize adverse drug events due to polypharmacy Project Objectives • Obtain commitment from 80% of QHA’ providers to encourage their patients and staff to participate in the Enhanced Medication Review study • Identify all medication non-compliance issues and barriers through survey results and develop patient specific plans to improve adherence • Ambulatory Care Managers report an overall positive confidence level in patients’ ability to self-manage their medication post intervention • Ambulatory Care Managers to complete post survey for each patient following medication review.
Methods & Activities
Results, cont.
Stakeholder Engagement and Survey Design
Table 2 Descriptive Characteristics for 28 completed Medication Reviews_
A. Program promotion and patient recruitment • Communication established in the form of elevator speech and meetings with patients and their families, primary care physicians, hospital nursing teams, and Home Care Nurses • Additional program promotion was done at monthly primary care practice meetings and monthly Skilled Nursing Facilities meetings • Patients were recruited by Ambulatory Care Managers during their inpatient stays or recommended by a primary care physician B. Survey Design • The Medication Review Questionnaire measured factors that contributed to polypharmacy in at risk older adults • The ambulatory Care Manager’s Post Survey was administered to assess patients ability to self-manage their medications and Care Managers confidence in patients ability to self-manage medications • The Provider Pre and Post Surveys were administered to identify providers participating in the Medication Review Program, and to gain feedback from providers
Variable Category Participants Participants ___________________________________ _ (n) (%)______ How many medications 0-5 1 3.6 were reviewed? 6-10 11 39.3 11-15 9 32.1 16-20 5 17.9 21 or more 2 7.1_____ Can the patient tell you YES 22 78.6 why he is taking the Rx? NO 6 21.4____ Were problems found during YES 13 46.4 the medication review? NO 15 53.6____ What problems were Duplicate RX 2 15.4 found? Failed to fill RX 4 30.8 Incorrect RX/Dose 6 46.2 Not taking as prescribed 4 30.8 Contraindications 1 7.7____ Were changes made YES 13 46.4 to the regimen NO 15 53.6 because of the review?_____________________________________________ Table 3 Descriptive characteristics by Ambulatory Care Manager's responses to post-medication review surveys _____________________________________ Participants(n)_________ Variable Mean ± SD or n (%)___ Did patient gain better understanding of their medication? YES 24 (85.7%) NO 4 (14.3%) What types of patient education was provided? Reason for Taking medication 14 (50%) Continued medication education 13 (46.4%) Education of dosage change 9 (32.1%) Refill reminders 6 (21.4%) Other 4 (14.3%) None 1 (3.57%) Are you confident in the patient's ability to self-manage? YES 20 (71.4%) NO 8 (28.6%)
Statistical Analysis A. Survey Results • Categorical variables were summarized with frequencies and percents • All results were analyzed using Microsoft Office Suite 2010
Results Table 1 Descriptive characteristics in 28 patients identified by Ambulatory Care Managers for the Enhanced Medication Review Pilot Program Category Participants Participants Variable Age
40-49 years 50-59 years 60-69 years 70-79 years 80-89 years 90 and over
Types of Chronic Condition
CHF COPD Table 1 Ohio Scale Results from Diabetes a Standard Hypertension CAD Asthma ESRD Cancer Individual With Multiple Chronic conditions
2 3 4 5 or More
a CHF=Congestive heart failure b COPD= Chronic obstructive pulmonary disease c CAD= Coronary artery disease d ESRD= End stage renal disease
(n)
(%)
1 2 2 13 9 1
3.6 7.1 7.1 46.4 32.1 3.6
10 11 14 24 11 5 1 12
36.7 39.3 50.0 85.7 39.3 17.9 3.6 42.9
12 7 6 1
42.9 25.0 21.4 3.6
Conclusions & Recommendations • • • • • •
Conclusion Overall Care Managers reported a moderate confidence (71.4%) level in patients ability to self-manage their medications All QHA providers agreed to participate in the pilot study and a post survey was completed for each patient by Care Managers Nearly all participating patients (93%) had two or more chronic conditions Recommendations The results from this study should be used to implement interventional programs to improve medication adherence and care coordination Include pharmacies in the project to better track patient medications Pilot the program with a single provider and assign a staff/care manager to the practice to improve participation in the program
References 1. Agency for Healthcare Research and Quality. (2015). Health literacy universal precautions toolkit: Conduct brown bag medicine reviews. Retrieved from https://www.ahrq.gov/professionals/quality-patient-safety/qualityresources/tools/literacy-toolkit/healthlittoolkit2-tool8.html 2. Older Adults. (n.d.). In Healthy People 2020. Retrieved April 9, 2018, from https://www.healthypeople.gov/2020/topics-objectives/topic/older-adults