1. Bringing medicine, patients, and community-based services together 1

2. Partners in Care Foundation Sandy Atkins, VP, Institute for Change HSAG University of Best Practices November 21, 2014 High Tech in Support of High Touch Care at Home

3. Partners in Care Foundation Who We Are Partners in Care serves as a catalyst for shaping a new vision of healthcare by partnering with organizations, families and community leaders in the work of changing healthcare systems, changing communities and changing lives— focusing on home and community care We evolved from the VNA of Los Angeles to be a nimble force for change.

4. The Problem Medication Errors are: Serious: Over 700,000 people go to ED each year for adverse drug events Costly:Drug-related morbidity/mortality $170 billion – in Y2K dollars! ER, hospital/readmissions, SNF etc. Common:Up to 48% of community-dwelling elders have medication-related problems Preventable:At least 25% of all harmful adverse drug events are preventable

5. Home visits uncover many “secrets” that providers may not know OTCs – Over-the-counter medications Prescriptions from other other providers Adverse effects such as falls, dizziness, confusion Adherence issues Out of system meds: Drugs from other countries, borrowed, Wal-Mart $4

6. HomeMeds SM Improves Med Safety Home visit by social worker, CHW, etc. – Collect comprehensive medication information – Assess for possible adverse effects & discrepancies – Screen through software to find potential problems Pharmacists review & resolve problems, educate Original Model: Find a home visit—add HomeMeds Emerging Models – Targeted home visits for high-risk patients – Add to care transitions, CDSMP, caregiver support, etc. – Part of comprehensive fall prevention initiative

7. HomeMeds: What it Is & How it Works “Any symptom in an elderly patient should be considered a drug side effect until proved otherwise.” (Gurwitz et al. 1995)

8. Core Components  Collect comprehensive medication list  Note how each drug is being taken  Record BP/pulse, falls, uncharacteristic confusion, symptoms, and indicators of adverse effects  Use evidence-based protocols to screen for risks  Computerized risk assessment and alert process  Consultant pharmacist addresses problems with prescribers, seniors, families & staff.

9. Risk-Screening Protocols HomeMeds is a TARGETED intervention addressing a limited group of medication related problems identified by national expert consensus panel ¹ Targets problems that can be identified and resolved in the home. Chosen to produce positive re sponse by prescribers Minimize “al ert overload”: based on signs/symptoms.  Limited to only these medication-related problems 1.Unnecessary therapeutic duplication 2.Use of psychotropic drugs in patients with a reported recent fall and/or confusion 3.Use of non-steroidal anti-inflammatory drugs (NSAID) in patients at risk of peptic ulcer/gastrointestinal bleeding 4.Cardiovascular medication problems -High BP, low pulse, orthostasis and low systolic BP ¹A model for improving medication use in home health care patients. Brown, N. J., Griffin, M. R., Ray, W. A., Meredith, S., Beers, M. H., Marren, J., Robles, M., Stergachis, A., Wood, A. J., & Avorn, J. (1998). Journal of the American Pharmaceutical Association, 38 (6), 696-702.

10. The first and most important step… Treasure hunt – find “hidden” meds Transcribe accurate information from the bottle/box Adherence Inquiry – For each medication ask client: – What they take it for – How and when they take it, – How much they take – What happens when they take it (Is it effective? Side effects? Assess for common side effects – Falls – Confusion – Dizziness, shakiness, feeling light headed – BP/pulse 10

11. Roles of the Pharmacist 11 Screen alerts to confirm problems Communicate with prescribers Consult with care manager Identify problems beyond protocols Assist with complex cases – simplify med regimen Educate staff

12. Typical Problems In Community-Dwelling Elders: Patient w/ mild cognitive impairment taking all medications – including sleeper & 3 doses of BP meds – in a.m. Patient with dizziness taking 2 beta blockers Patient >80 taking 3 medications that increased risk of GI Bleed Patient who fell w/ 5 meds that increased risk of falls Patient taking 4 narcotic pain killers Avg. 11 meds – many with 28+! 12

13. HomeMeds-Plus

14. HomeMeds-Plus: What is it? Home Evaluation and Needs Assessment 2 hour home visit – HomeMeds comprehensive medication risk assessment – Home Safety and Fall Risk evaluation – Functional and Psychosocial assessment PHQ 2/9 Mini mental ADL/IADL – Advance Directive education and assistance Pharmacist follow-through on medication problems Develop community service plan with member Coordination of community resources Collaboration with plan/medical group case managers

15. HomeMeds-Plus: Who Benefits? Who is it for? Adults with 2+ chronic conditions and other risks: – Recent history of ED visits or unplanned hospitalizations &/or – 5-9 prescribed meds &/or – Some functional impairment &/or – Mild to moderate cognitive impairment &/or – Possible caregiver needs or social challenges &/or – Live Alone &/or – Self-management issues (significantly off goal for chronic diseases)

16. Value Proposition 1 - ROI Compared to patients who met referral criteria but did not receive the intervention – 12.8% lower rate of ED use – 22% lower readmission rate (9.1% readmitted vs. 11.6% readmitted) – 50% ROI Compared to overall readmissions for the medical group at the same hospital – 40% lower readmission rate – $224,000 cost avoidance on $88,000 investment 90% Uptake on qualified referrals

17. Value Proposition 2 - Quality Addresses HEDIS measures – Fall risk management – Medication reconciliation post-discharge Required by NCQA for Health Plans – Potentially harmful drug-disease interactions – Blood pressure control – Antidepressant medication management – Health Plan all-cause readmissions "No risk factor for falls is as potentially preventable or reversible as medication use. (Leipzig, 1999)

18. Star Ratings – Medicare Advantage Yearly review of all medications/supplements – % 65+ who fell or had problems with balance or walking in past 12 mo. who received fall risk intervention Controlling blood pressure – Medication adherence for hypertension: Taking meds as directed Plan members 65+ on high-risk drugs, when there may be safer drug choices Reducing risk of falling Readmission to a hospital within 30 days of discharge Yearly pain screening or pain management plan Bonuses for 4 & 5 Star Plans – growing!!

19. Costly Mistakes Inpatient: Fx Hip & Thigh Bone $53,247 (7 days) Shoulder, Wrist, Hand (JPS) $31,148 (2 days) Total Cost = $70,434 Rehabilitation: (HealthSouth) $17,187 (10 days) Fall Prevention = Savings

20. HomeMeds: Software, Startup

21. Web-based: Use with PC or Tablet

22. HomeMeds Software: Dashboard 22

23. HomeMeds Software: Risk Assessment 23

24. HomeMeds Software: Medications 24

25. Sample Medications List 25

26. Conclusion HomeMeds is a proven tool for improved medication safety, health and well-being for older adults. It is an affordable, evidence-based program that is a perfect bridge for partnerships between community agencies and healthcare.

27. Contact Information Sandy Atkins, VP: satkins@picf.orgsatkins@picf.org Phone: 818.837.3775 Partners in Care Website: www.picf.orgwww.picf.org