Medication management: evidence brief. Center for Home Care Policy & Research

Medicines Management, Medication Errors and Adverse Medication Events in Older People Referred to a Community Nursing Service: A Retrospective Observational Study

BACKGROUND

Increasing numbers of older people are receiving support with medicines management from community nursing services (CNSs) to enable them to live in their own homes. Little is known about these people and the support they receive.

OBJECTIVES

To explore the characteristics of older people referred for medicines management support, type of support provided, medication errors and adverse medication events (AMEs).

METHODS

A retrospective observational study of a random sample of 100 older people referred to a large non-profit CNS for medicines management support over a 3-month period was conducted. Measures were: demographics, referral source, current medical problems, medicines, medication aids, types of medication authorisations used by nurses, frequency of nurse visits and type of support provided, medication errors, AMEs and interdisciplinary teamwork among community nurses, general practitioners and pharmacists.

RESULTS

Older people (median 80 years) were referred for medicines support most often by hospitals (39 %). Other referrals were from families/carers, case-managers, palliative care services and general practitioners. Multiple health conditions (median 5) and medicines (median 10) were common; 66 % used ≥5 medicines; 48 % used ≥1 high-risk medicines-most commonly opiates, anticoagulants and insulin. Medication aids were frequently used, mostly multi-compartment dose administration aids (47 %). Most people received regular community nurse visits (≥4 per week) to administer medicines or monitor medicine-taking. Only 16 % had a medication administration chart; for other clients nurses used medicine lists or letters from doctors for medication authorisation. Medication errors occurred in 41 % of people and 13 % had ≥1 AME requiring medical consultation or hospitalisation; 9/13 (64 %) AMEs were potentially preventable. There was little evidence of interdisciplinary teamwork or medication review.

CONCLUSION

CNS clients had multiple risk-factors for medication misadventure. Deficiencies in medicines management were identified, including low use of medication charts and interdisciplinary medication review. Strategies are needed to improve medicines management in the home-care setting.

Integrating a pharmacist into a home healthcare agency care model: impact on hospitalizations and emergency visits

Medication regimens can be complicated during the transition from hospital to home for a variety of reasons. The primary purpose of this retrospective study was to measure the impact of integrating a pharmacist into a model of care at a Medicare-certified home healthcare agency for clients recently discharged from the hospital. The secondary purpose was to describe the medication-related problems among clients receiving services from the model of care involving a pharmacist. Integrating a pharmacist within the model of care demonstrated a positive clinical impact on clients.

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.

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

BACKGROUND

Self-management of complex medication regimens for chronic illness is challenging for many older adults.

OBJECTIVES

The purpose of this study was to evaluate health status outcomes of frail older adults receiving a home-based support program that emphasized self-management of medications using both care coordination and technology.

DESIGN

This study used a randomized controlled trial with three arms and longitudinal outcome measurement.

SETTING

Older adults having difficulty in self-managing medications (n = 414) were recruited at discharge from three Medicare-certified home healthcare agencies in a Midwestern urban area.

METHODS

All participants received baseline pharmacy screens. The control group received no further intervention. A team of advanced practice nurses and registered nurses coordinated care for 12 months to two intervention groups who also received either an MD.2 medication-dispensing machine or a medplanner. Health status outcomes (the Geriatric Depression Scale, Mini Mental Status Examination, Physical Performance Test, and SF-36 Physical Component Summary and Mental Component Summary) were measured at baseline and at 3, 6, 9, and 12 months.

RESULTS

After covariate and baseline health status adjustment, time × group interactions for the MD.2 and medplanner groups on health status outcomes were not significant. Time × group interactions were significant for the medplanner and control group comparisons.

DISCUSSION

Participants with care coordination had significantly better health status outcomes over time than those in the control group, but addition of the MD.2 machine to nurse care coordination did not result in better health status outcomes.

Late-Life Depression in Home Healthcare

Major depression is disproportionately common among elderly adults receiving home healthcare and is characterized by greater medical illness, functional impairment, and pain. Depression is persistent in this population and is associated with numerous poor outcomes such as increased risk of hospitalization, injury-producing falls, and higher health care costs. Despite the need for mental health care in these patients, significant barriers unique to the home healthcare setting contribute to under-detection and under-treatment of depression. Intervention models target the home healthcare nurse as liaison between patients and physicians, and instruct in the identification and management of depression for their patients. Successful implementation requires interventions that 'fit' how home healthcare is organized and practiced, and long distance implementation strategies are required to increase the reach of these interventions.

Depression Care for Patients at Home (Depression CAREPATH): home care depression care management protocol, part 2

High levels of depressive symptoms are common and contribute to poorer clinical outcomes even in geriatric patients who are already taking antidepressant medication. The Depression CARE for PATients at Home (Depression CAREPATH) intervention was designed to meet the needs of medical and surgical patients who suffer from depression. The intervention's clinical protocols are designed to guide clinicians in managing depression as part of routine home care.