Nurse care coordination and technology effects on health status of frail older adults via enhanced self-management of medication: randomized clinical trial to test efficacy

Continuity of medication management and continuity of care: Conceptual and operational considerations

Objective:

Continuity of care is considered foundational to high-quality care. Traditional continuity of care constructs may adequately characterize care quality in general populations, but may merit reconceptualization for patients with multiple chronic conditions. Specifically, interactions between multiple chronic condition patients and providers involve complex medication management; therefore care continuity measurement may be more relevant if focused on the provider subset who prescribes essential medications for chronic conditions—a construct we call continuity of medication management. Our objective was to explore conceptual distinctions between continuity of medication management and continuity of care, survey existing evidence in this area, and discuss implications of our findings for future research and intervention development.

Methods:

In this topical review, we discuss conceptual distinctions between continuity of medication management and continuity of care, review the limited continuity of medication management–related empirical evidence, and discuss implications for future research and interventions.

Results:

Continuity of medication management represents a potential conceptual and measurement advance by reflecting interpersonal continuity and management continuity, and may provide a means of identifying patients at high-risk of adverse events. Empirical evidence also establishes support for continuity of medication management as a meaningful measure of care continuity. Finally, continuity of medication management may also be a potential target for future intervention to improve care delivery among multiple chronic condition patients.

Conclusion:

If continuity of medication management is validated in diverse populations, correlated with patient outcomes, and responsive to change, then it may be an important target for improving the health and health care of multiple chronic condition patients.

Cost analysis of a home-based nurse care coordination program

Objectives

To determine whether a home-based care coordination program focused on medication self-management would affect the cost of care to the Medicare program and whether the addition of technology, a medication-dispensing machine, would further reduce cost.

Design

Randomized, controlled, three-arm longitudinal study.

Setting

Participant homes in a large Midwestern urban area.

Participants

Older adults identified as having difficulty managing their medications at discharge from Medicare Home Health Care (N = 414).

Intervention

A team consisting of advanced practice nurses (APNs) and registered nurses (RNs) coordinated care for two groups: home-based nurse care coordination (NCC) plus a pill organizer group and NCC plus a medication-dispensing machine group.

Measurements

To measure cost, participant claims data from 2005 to 2011 were retrieved from Medicare Part A and B Standard Analytical Files.

Results

Ordinary least squares regression with covariate adjustment was used to estimate monthly dollar savings. Total Medicare costs were $447 per month lower in the NCC plus pill organizer group (P = .11) than in a control group that received usual care. For participants in the study at least 3 months, total Medicare costs were $491 lower per month in the NCC plus pill organizer group (P = .06) than in the control group. The cost of the NCC plus pill organizer intervention was $151 per month, yielding a net savings of $296 per month or $3,552 per year. The cost of the NCC plus medication-dispensing machine intervention was $251 per month, and total Medicare costs were $409 higher per month than in the NCC plus pill organizer group.

Conclusion

Nurse care coordination plus a pill organizer is a cost-effective intervention for frail elderly Medicare beneficiaries. The addition of the medication machine did not enhance the cost effectiveness of the intervention.

Assessing the impact of cognitive impairment on the usability of an electronic medication delivery unit in an assisted living population

PURPOSE

To examine the relationship between cognitive status and the usability of an integrated medication delivery unit (MDU) in older adults who reside in an Assisted Living Facility (ALF).

METHODS

Subjects were recruited from a single ALF in Pittsburgh, PA. Usability testing sessions required subjects to execute tasks essential to using EMMA(®) (Electronic Medication Management Assistant), a Class II Federal Drug Administration (FDA) approved integrated MDU. Video coding allowed for quantification of usability errors observed during the testing sessions. Each subject's cognitive status was assessed using the Mini Mental State Exam (MMSE(®)) with scores <24 indicating cognitive impairment. Functional status was assessed using the Lawton Instrumental Activities of Daily Living (IADL) questionnaire, and a global assessment of subjective usability was assessed by completing the System Usability Scale (SUS). Non-parametric statistics and correlation analysis were used to determine whether significant differences existed between cognitively impaired and non-impaired subjects.

RESULTS

Nineteen subjects were recruited and completed the protocol. The subject pool was primarily white, female, 80+ and in possession of above average education. There was a significant relationship between MMSE(®) scores and the percentage of task success (z=-2.03, p=0.04). Subjects with MMSE(®) scores of 24+ (no cognitive impairment) successfully completed an average of 69.0% of tasks vs. the 34.7% performance for those in the cognitively impaired group (<24). Six of the unimpaired group also succeeded at meeting the 85% (6 out of 7 correct) threshold. No subject with cognitive impairments (<24 MMSE(®)) completed more than 5/7 (71.4%) of their tasks. Two of the impaired subjects failed all of the tasks. Three of the MMSE(®)'s subsections (Date, Location and Spell 'world' backwards) were found to be significantly related (p<0.05) to the percentage of task success. Tasks success rates were related with IADL scores (z=-3.826, p<0.0001), and SUS scores (r=0.467, p=0.0429).

CONCLUSIONS

Medication delivery units like EMMA(®) have the potential to improve medication management by combining reminder systems with telemedical monitoring and control capabilities. However, subjects judged to be "cognitively impaired" (<24 MMSE(®)) scored a significantly smaller percentage of task success than the "unimpaired" (>=24), suggesting that cognitive screening of patients prior to the use of EMMA(®) may be advisable. Further studies are needed to test the use of EMMA(®) amongst ALF residents without cognitive impairment to see if this technology can improve medication adherence.