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 65-007)

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

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

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

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% Any29948.6%18129.4% Ther. Duplication14924.2%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% ∆ Any16226.3%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 -- 2+ states NCOA Readiness Tool Seeking potential sites for 2008

30. Photo by JL Forter