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Detecting & Improving Medication Use Among Vulnerable Elders: A Community-Based Medication Management Intervention Gretchen Alkema VA Greater Los Angeles.

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Presentation on theme: "Detecting & Improving Medication Use Among Vulnerable Elders: A Community-Based Medication Management Intervention Gretchen Alkema VA Greater Los Angeles."— Presentation transcript:

1 Detecting & Improving Medication Use Among Vulnerable Elders: A 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 )

3 Problem of Medication Errors 65+ = 12% of population but consume ⅓ of all drugs % 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

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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 (N=615) Site #1: n=216 Site #3: n=126 Site #2: n=273

9 Targeted Medication Problems (Brown et al., 1998, Meredith et al., 2001) 1. Unnecessary therapeutic duplication 2. Psychotropic drug use w/ confusion or falls 3. Cardiovascular medication problems 4. Use of non-steroidal anti-inflammatory drugs (NSAIDs) with peptic ulcer risk

10 Research Design

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13 Care Management Sample (N=615) 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 (N=615)

15 Language Preference (N=615)

16 Health Status (N=615) Mean # of meds = 8.76 (SD=4.3); 12+ meds = 22% 38% ED, Hospital, or SNF in previous year 22% falls in previous 3 months 27% dizziness 31% confusion

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22 Attrition 10 left before med problems confirmed ↑ fallers (p<.05) 100% w/ 1+ potential problem (p<.001) 19 left before intervention completed ↓ # of meds (p<.05) Main reasons: LTC, died, or moved

23 Prevalence Results (N=615) PotentialConfirmed Medication ProblemN%N% Any % % Ther. Duplication %8714.1% Psychotropic8814.3%6510.6% Cardiovascular8714.1%274.4% NSAIDs7912.8%538.6%

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 Screening to Intervention Medication Change at 3 Months (N=615)(N=162) Medication ProblemN%N% ∆ Any %9961.1% Ther. Duplication7912.8%4962.0% Psychotropic599.6%2367.6% Cardiovascular243.9%1145.8% NSAIDs447.2%2250.0% Intervention Results (N=162)

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 doctor…some 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 states NCOA Readiness Tool Seeking potential sites for 2008

30 Photo by JL Forter


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