Issues in the Medication Management Process in People Who Have Intellectual and Developmental Disabilities: A Qualitative Study of the Caregivers' Perspective

Medication management issues perceived by pharmacists and disability caregivers while supporting people with disability

Background

Australia has a notable gap in guidance for pharmacists, caregivers and disability service providers in: (i) supporting people with disabilities (PWD) within the medication management cycle, (ii) understanding their obligations for providing high quality care, and (iii) preventing medication-related harm.

Objective

The objective of this study was to identify medication management issues for PWD from the perspective of disability caregivers and pharmacists when supporting PWD with their medication.

Methods

A qualitative study design using semi-structured interviews of pharmacists and disability caregivers was undertaken across six different states or territories in Australia.

Results

Interviews were conducted with registered pharmacist participants (n=10), and disability workers (n=10). Seven themes emerged for both pharmacists and caregivers, with most sub-themes and codes concordant between the two cohorts. Clinical issues, particularly related to polypharmacy and psychotropic use; confidence in providing medicines and medication information accurately to PWD; practical and behavioural issues caregivers experienced when administering medication; challenges in providing individualised and person-centred care to PWD; inadequate communication and transfer of information between healthcare professionals, caregivers, and PWD; insufficient disability awareness training for pharmacists and medication training for caregivers; and challenges working with provider organisations within the current practice environment were described.

Conclusions

This study highlighted seven areas where issues were perceived to arise in medication management for PWD. By understanding the issues perceived by those directly providing care, it may be possible to improve medication management. Further research is needed to understand the perceived role of pharmacists in supporting medication management for PWD and their caregivers, and how enabling pharmacists scope might reduce medication-related risks and support QUM in this sector.

Medicaid long-term services and supports and caregiving needs of caregivers of individuals with intellectual and developmental disabilities

BACKGROUND

Long-term care services are funded primarily by Medicaid long-term services and support in the United States, where eligibility is based on care needs of the individual with intellectual and developmental disability alone. Impact of Medicaid waiver services on self-reported caregiver needs is not well understood.

METHOD

Caregivers (n = 405) of individuals with intellectual and developmental disabilities across four states (NY, OH, TX, and PA) completed an online survey.

RESULTS

Caregivers reported a moderate degree of burden and susceptibility of stress-induced health breakdown. Despite controlling for the activities of daily living of the care recipient, caregivers of individuals with Medicaid Waiver services reported greater difficulty managing medications (p = .013) and finding paid help (p < .001) than caregivers of individuals without services.

Intellectual disability nurses' challenges in medication management in primary health care: A qualitative study

This study examines how intellectual disability nurses employed in residential living services for persons with intellectual disabilities, in Norway, deal with medication management for these individuals. Using a qualitative study, a total of 18 intellectual disability nurses were interviewed as part of four focus groups. The results demonstrate six main challenges: First, Being alone with the responsibility of medication management - a challenge; Second, The need for further competence development; Third, Teaching and supervising unskilled colleagues in safe medication management; Fourth, Interpreting residents with little or only nonverbal communication; Fifth, The need to act as advocates when residents require hospitalization; Sixth, Deficient systems for medication management on several levels. The findings point to several major flaws in the system of medication management, which necessitates the need for highly qualified intellectual disability nurses. Managers must ensure that there is a secure system to mitigate errors and promote patient safety.

Challenges and responsibilities in the medication management process in 24/7 group housing services for adults with intellectual disability: Interviews with nurses

Staff in 24/7 group housing services for adults with intellectual disability are responsible for ensuring safe medication management processes and supporting the residents in their health-related issues. Ten interviewed nurses reported several challenges in the medication management process emerging at the staff level, the level of the group home, and the level of the social and healthcare system, and were often related to issues in communication and responsibility. They reported a variety of complex tasks in the medication management process, for which they need a multiple skill set. They also act as healthcare advocates for residents, but healthcare services do not always match residents' needs. Training for social and healthcare professionals, access to healthcare services and the collaboration of social and healthcare services should be improved to provide the people with intellectual disability the best possible pharmacotherapy and healthcare.

A Randomized Controlled Trial using Brief Educational Messages Directed to Adults with Intellectual Disability and Hypertension or their Helpers Reduces Hospital Stays

PURPOSE

We assessed an educational intervention to reduce the number of emergency department (ED) and inpatient stays for cardiovascular diagnoses, among South Carolina adult Medicaid Members with intellectual and developmental disability and hypertension (Members).

DESIGN

This Randomized Controlled Trial (RCT) included Members or the person who helped them with their medications (Helpers). Participants, who included Members and/or their Helpers, were randomly assigned to an Intervention or Control group.

SETTING

South Carolina Department of Health and Human Services, which administers Medicaid, identified eligible Members.

SAMPLE

412 Medicaid Members - 214 Intervention (54 Members participating directly; 160 Helpers participating in lieu of Members) who received the messages about hypertension and surveys about knowledge and behavior and 198 Controls (62 Members; 136 Helpers) who only received surveys of knowledge and behavior.

INTERVENTION

Educational intervention about hypertension included a flyer and monthly text or phone messages for one year.

MEASURES

Input measures - characteristics of the Members; Outcome measures - hospital emergency department (ED) and inpatient visits for cardiovascular conditions.

ANALYSIS

Quantile regression tested the association of Intervention/Control group status with ED and inpatient visits. We also estimated models using Zero-inflated Poisson (ZIP) models for sensitivity analysis.

RESULTS

Participants in the Intervention group with highest baseline hospital use (top 20% ED; top 15% Inpatient) had significant reductions in Year 1 (.57 fewer ED and 2 fewer inpatient days) compared to the Control group. For ED visits, improvement continued in year two.

CONCLUSION

The intervention reduced the frequency of cardiovascular disease-related ED visits and Inpatient days for participants in the Intervention group in the highest quantiles of hospital use, and the improvement was better for those who had a Helper.

Short Report: Where do caregivers of persons with intellectual or developmental disabilities obtain information about medication?

BACKGROUND/AIMS/METHODS

Medication information is available from many sources. This short report provides a simple description of where caregivers of people with intellectual/developmental disability (IDD) obtain medication information, and compares these sources between family caregivers and direct support professionals (DSP).

PROCEDURES/OUTCOMES

Cross-sectional study design using an internet-based survey of caregivers, aged 18 years or older, who provided support to adults with IDD. The primary outcome is the source of medication information reported by caregivers.

RESULTS/CONCLUSIONS

Eighty-nine caregivers responded. Health care professionals were the primary source (87.6 %) of medication information, followed by the internet (77.5 %). There was no difference between caregiver groups for these two sources. The prescription label/information sheet was the next most common source (56.2 %), with significantly more family (76.2 %) versus DSP (38.3 %), p < 0.001. A medication reference was also common (43.8 %), with 28.6 % of family and 57.4 % of DSP, p = 0.006. House manager/nurse was next, with 16.9 %, and television/radio as a source (10.1 %), no difference between groups. Lastly, friends or coworkers were 7.9 %, with no DSP endorsing this option, p = 0.006.

IMPLICATIONS

Caregivers obtain medication information from a variety of sources, with health care professionals being the primary source. The internet was also very common, which may be worrisome, due to the wide range of level of quality of information available. Educational interventions should be developed to provide caregivers with tools to be able identify and use legitimate medication information.

Healthcare inequities among adults with developmental disability: An integrative review with implications for nursing education

AIM

This integrative review synthesized research on the healthcare inequities experienced by adults with developmental disability in the United States and discussed implications for nursing education.

BACKGROUND

Individuals with developmental disability are living longer with chronic comorbidities and experience healthcare inequities.

METHOD

Application of inclusion criteria to database and ancestry searches resulted in 26 articles that were assessed for quality and analyzed thematically.

RESULTS

Three categories of inequity were identified: knowledge deficits, communication challenges and poor quality of care. Knowledge deficits and communication challenges can lead to frustration, errors and unmet needs. Poor quality of care encompasses the decreased availability and access to services, limited health promotion participation and higher rates of hospitalizations and complications for adults with developmental disability.

CONCLUSION

Healthcare inequities may be reduced by targeting patient and provider knowledge. Inclusion of developmental disability content and clinical experiences in nursing education may improve care and reduce inequities for this underserved population.

Medication management in intellectual disability settings: A systematic review

There is a high level of medication usage among people with intellectual disability due to the presence of significant morbidity and co-morbidities. This review sought to explore medication management and administration in intellectual disability settings, identifying frameworks for practice, analysing whether collaborative practice led to better outcomes, identifying key processes associated with practice, locating tools to support practice and describing metrics for outcome measurement. A systematic review was conducted with analysis of 64 sources which remained following screening and appraisal. Limited evidence was identified with some insight into the processes underpinning medication management and administration. No assessment tools were found, but two potential outcome measures, adherence and errors, were noted. The paucity of guidelines and frameworks is concerning as this is a complex area of practice. There is a need for further practice development and research to be undertaken that takes note of the unique issues that can present in intellectual disability settings.

Medication-related knowledge, administration practice and adherence among caregivers of chronically ill children in Malaysia

Background

Caregivers’ knowledge, practice and adherence in medication administration who care for children with chronic illness requiring long-term pharmacological treatments are factors associating with children medication safety at home. This study aimed to determine the medication-related knowledge, administration practice and adherence among caregivers of chronically ill children in Malaysia. This cross-sectional study was conducted at the paediatric outpatient clinic of a tertiary public hospital. Caregivers of chronically ill children, who engaged in medication administration at home for at least 3 months, were conveniently recruited. Their medication-related knowledge and administration practice were evaluated based on a checklist, while their adherence to medication administration was assessed using a validated 5-point scale. The associated factors were also explored.

Results

Of the 141 participants, most were mothers (90.8%) and had a full-time job (55.3%). Most of them had adequate medication-related knowledge (71.6%) and an appropriate administration practice (83.0%). The majority of them (83.0%) also rated themselves as adherent to medication administration. The participants with a child above 5 years of age (91.2%) were found to have a better practice than those with younger children (75.3%) in medication administration (p = 0.012). However, those with a child taking two (adjusted OR: 12.53) or three (adjusted OR: 8.29) medications, getting their refills from private health institutions apart from this hospital (adjusted OR = 7.06) and having multiple illnesses (adjusted OR = 21.25) were more likely to be not adherent to medication administration.

Conclusion

Caregivers of chronically ill children in Malaysia generally have sufficient knowledge and an appropriate practice of medication administration at home. Yet, strategies to improve the adherence to medication administration, particularly in those who care for children with complicated health conditions, are warranted.

In-home comprehensive medication reviews for adults with intellectual or developmental disability: A pilot study

OBJECTIVES

To assess the feasibility of conducting in-home comprehensive medication reviews (CMRs) and to identify and intervene when appropriate for medication-related problems (MRPs) found in medication regimens taken by people with an intellectual or developmental disability.

SETTING

Community-based group homes in southeast Michigan.

PRACTICE DESCRIPTION

Implementation and evaluation of a pilot program conducting CMRs within community-based group homes.

PRACTICE INNOVATION

An in-home CMR conducted by a clinical pharmacist.

EVALUATION

Identified MRPs, pharmacist recommendations, recommendation acceptance, time spent directly on intervention, and barriers to implementation.

RESULTS

CMRs were conducted for 15 patients identified as receiving 5 or more medications by their community support agency. Thirty-six MRPs were identified (mean ± SD of 2.4 ± 1.5 per person). The most common MRPs were a medication that was being taken with no indication for its use (7 occurrences) and identification of an untreated medical problem (7). Other MRPs included wrong dose (5); patient or caregiver indicated that the medication was not working (4); wrong dosage form was being used or given (3); duplication of therapy (2); pharmacy error (2); extended release medications were being crushed before administration (2); and wrong administration time, drug ordered but not given, drug-disease potential interaction, and poor drug administration technique (1 for each). The interventions included sending information letters to the group home manager containing information to be discussed with the patient's physician or telephone calls made directly to the prescriber or pharmacy. The interventions made by telephone calls to prescribers included 3 calls to physicians to discuss 5 MRPs, and 3 telephone calls for pharmacy-related MRPs, all of which were accepted.

CONCLUSION

The results of this prospective pilot project provide justification to further explore the role of conducting independent CMRs for patients with an intellectual or developmental disability living in the community to ensure safe and effective use of their medications.

Pharmacist interventions for persons with intellectual disabilities: A scoping review

INTRODUCTION

Persons with intellectual disabilities (ID) often have complex health needs due to the development of multiple comorbidities. Given the higher associated use of problematic medications, such as antipsychotics, and polypharmacy, persons with ID may be particularly vulnerable to adverse side effects. With their medication expertise, pharmacists have the potential to address medication related challenges experienced by this population.

OBJECTIVE

Explore what is known about the care pharmacists provide to persons with ID.

DESIGN

Following Arksey and O'Malley's 5-stage framework for scoping reviews, searches of the PubMed (MEDLINE), Ovid EMBASE, Ovid International Pharmaceutical Abstracts, Scopus and APA PsycINFO databases were conducted in January 2019 with no limits on publication date. Studies of participants diagnosed with ID or healthcare providers/caregivers of persons with ID that referenced a pharmacist care intervention were included. Studies with non-human populations and editorials, commentaries, letters to the editor or discussion papers were excluded.

RESULTS

Twenty-six studies were included in the review. Seventy-six pharmacist care interventions were identified in cognitive pharmacy services (n = 46); educational and advisory services (n = 20); and medication prescription processing (n = 10). Fifty-one outcomes were referenced including drug-related interventions (n = 14), drug related problems (n = 9), cost/time-effectiveness (n = 7), secondary symptoms (n = 6), other outcomes (n = 5), general medication usage (n = 4), caregiver and healthcare team satisfaction levels (n = 3), and educational/knowledge (n = 3).

CONCLUSION

Pharmacists perform a variety of health care services to persons with ID but the impact of these interventions cannot be accurately measured due to a lack of: 1) universal definitions for ID; 2) reporting of multifactorial conditions contributing to a spectrum of ID severity; and 3) standardized reporting of ID-specific outcomes. Addressing these gaps is necessary for the development of a comprehensive evidence base regarding pharmacist involvement for medication challenges in persons with ID.

Adverse Medication Events Related to Hospitalization in the United States: A Comparison Between Adults With Intellectual and Developmental Disabilities and Those Without

This study examined the proportion of hospitalizations associated with adverse medication events (AMEs) for adults with intellectual and developmental disabilities (IDD) and adults from the general population in the United States using the 2013 National Inpatient Sample (NIS) dataset of the Healthcare Cost and Utilization Project (HCUP). Adults with IDD had greater odds of having a hospitalization associated with an AME than the general adult population. Unadjusted odds ratios (95% CI) for hospitalization due to any medication for IDD was 2.47 (2.31-2.65). In the multivariate logistic regression model, IDD was significantly associated, with an odds ratio of 1.28 (1.19-1.38). Adults who have IDD are at greater risk of having a hospital admission due to an AME.

Direct Support Professionals' Perspectives on Ambulatory Health Care Processes and Quality

Direct support professionals (DSPs) frequently accompany persons with intellectual and other developmental disabilities (IDD) to their health care appointments and could offer valuable insights into potential target areas for health-care improvement. DSPs completed surveys assessing healthcare processes and quality immediately following 118 ambulatory health care encounters involving their patients with IDD. Although DSPs generally judged the quality of health care as good (44%) or excellent (52%), they also observed that physicians directed questions to the DSP that the patient could have answered in 22% of encounters, and noted that physicians failed to ask critical psychosocial information in 24% of encounters. Competency-based training of DSPs around health-care advocacy could significantly improve the quality of health care provided to persons with IDD.

Identifying Medication Management Smartphone App Features Suitable for Young Adults With Developmental Disabilities: Delphi Consensus Study

BACKGROUND

Smartphone apps can be a tool to facilitate independent medication management among persons with developmental disabilities. At present, multiple medication management apps exist in the market, but only 1 has been specifically designed for persons with developmental disabilities. Before initiating further app development targeting this population, input from stakeholders including persons with developmental disabilities, caregivers, and professionals regarding the most preferred features should be obtained.

OBJECTIVE

The aim of this study was to identify medication management app features that are suitable to promote independence in the medication management process by young adults with developmental disabilities using a Delphi consensus method.

METHODS

A compilation of medication management app features was performed by searching the iTunes App Store, United States, in February 2016, using the following terms: adherence, medication, medication management, medication list, and medication reminder. After identifying features within the retrieved apps, a final list of 42 features grouped into 4 modules (medication list, medication reminder, medication administration record, and additional features) was included in a questionnaire for expert consensus rating. A total of 52 experts in developmental disabilities, including persons with developmental disabilities, caregivers, and professionals, were invited to participate in a 3-round Delphi technique. The purpose was to obtain consensus on features that are preferred and suitable to promote independence in the medication management process among persons with developmental disabilities. Consensus for the first, second, and third rounds was defined as ≥90%, ≥80%, and ≥75% agreement, respectively.

RESULTS

A total of 75 responses were received over the 3 Delphi rounds-30 in the first round, 24 in the second round, and 21 in the third round. At the end of the third round, cumulative consensus was achieved for 60% (12/20) items in the medication list module, 100% (3/3) in the medication reminder module, 67% (2/3) in the medication administration record module, and 63% (10/16) in the additional features module. In addition to the medication list, medication reminder, and medication administration record features, experts selected the following top 3 most important additional features: automatic refills through pharmacies; ability to share medication information from the app with providers; and ability to share medication information from the app with family, friends, and caregivers. The top 3 least important features included a link to an official drug information source, privacy settings and password protection, and prescription refill reminders.

CONCLUSIONS

Although several mobile apps for medication management exist, few are specifically designed to support persons with developmental disabilities in the complex medication management process. Of the 42 different features assessed, 64% (27/42) achieved consensus for inclusion in a future medication management app. This study provides information on the features of a medication management app that are most important to persons with developmental disabilities, caregivers, and professionals.

Health Services Use and Costs for Americans With Intellectual and Developmental Disabilities: A National Analysis

Health services and associated costs for adults with intellectual and developmental disabilities (IDD) were nationally profiled and the predictors of high expense users statistically modeled. Using linked data from the National Health Interview Survey and Medical Expenditure Panel Survey for the years 2002 through 2011, the study found a mixed pattern of differences in rates of service use and costs when compared to the general population depending upon personal characteristics, health status, and type of health care service. Prescription medication costs were the primary driver of total health care expenditures for Americans with IDD. The presence of secondary chronic health conditions and poor mental health status were the consistent predictors of high expense users across types of health care. Study results are discussed in terms of implications for more nuanced evaluations of health care costs and need for recurring surveillance of health care for Americans with IDD in the years following passage of the Patient Protection and Affordable Care Act.