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

Bringing medicine, patients, and community-based services together

1

Partners in Care FoundationSandy Atkins, VP, Institute for Change

HSAG University of Best PracticesNovember 21, 2014

High Tech in Support of High Touch Care at Home

Partners in Care FoundationWho 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.

The Problem

Medication Errors are:Serious: Over 700,000 people go to ED each year for

adverse drug eventsCostly: 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

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

HomeMedsSM 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

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)

Core Components

Collect comprehensive medication listNote how each drug is being takenRecord BP/pulse, falls, uncharacteristic confusion,

symptoms, and indicators of adverse effectsUse evidence-based protocols to screen for

risks Computerized risk assessment and alert

processConsultant pharmacist addresses problems

with prescribers, seniors, families & staff.

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 response by prescribers• Minimize “alert overload”: based on signs/symptoms.

Limited to only these medication-related problems

1. Unnecessary therapeutic duplication2. Use of psychotropic drugs in patients with a reported recent fall

and/or confusion3. Use of non-steroidal anti-inflammatory drugs (NSAID) in

patients at risk of peptic ulcer/gastrointestinal bleeding4. 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.

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

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

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

HomeMeds-Plus

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

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)

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

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)

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 planBonuses for 4 & 5 Star Plans – growing!!

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

HomeMeds: Software, Startup

Web-based: Use with PC or Tablet

HomeMeds Software: Dashboard

22

HomeMeds Software: Risk Assessment

23

HomeMeds Software: Medications

24

Sample Medications List

25

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.

Contact Information

• Sandy Atkins, VP: satkins@picf.org• Phone: 818.837.3775• Partners in Care Website: www.picf.org