Recorded Live StreamChanges to the Home Health Landscape: Pharmacists Join the Team with Lisa Sever (1.0 CEUs, accreditation file number 8002-2017-2126-I-P)

Learning Objectives: 1. Identify the value of adding a pharmacist to the home health environment2. Describe barriers and challenges to establishing the home health pharmacist role3. Characterize ideal pharmacist traits to support home health care4. Articulate change concepts to support the integration of the home health

pharmacist

Reviewers’ CommentaryThis recorded session has been expert reviewed and our reviewer offers these comments on the content:

Slide 47: Access to documentation can be challenging and depends on pharmacists employer, state of province’s/health region’s level of IT health record.

Slide 48: A consent process should be included under list of items where pharmacists need support.

Discussion: “In my experience, many nurses in home care are only ware of the dispensing role of pharmacists. Clinical pharmacists are more commonly encountered by nurses in acute care practice.”

“Lisa passionately voices the collective frustration with the current state of support for seniors living at home and at risk of medication related problems. She clearly articulates the necessary elements for change. Her rallying cry needs to be heard by politicians, public health, acute care and community administrators. Implementation of sustainable, integrated, clinical pharmacy services in the community is a critical complete of restructuring health care in Canada.”

Changes to the Home Health Landscape

Pharmacists Join the Team

Lisa Sever, BScPHM, ACPR, CGP, RPhConsultant Pharmacist, Home Care Rx Inc.

Disclosure

The speaker has no financial or other conflicts of interest to report

Aging Population in Canada

Source: Statistics Canada (1971-2010) and Office of the Superintendent of Financial Institutions (2020-2080) www.Canada.ca

Seniors on ++ medications

http://www.theglobeandmail.com/life/health-and-fitness/health-advisor/multiple-medications-are-a-problem-for-seniors-heres-how-to-reduce-the-risks/article31134431/

http://www.cbc.ca/news/canada/manitoba/prescription-drug-use-among-seniors-far-too-high-1.3596006

Risk Points – Hospital to Home

• 35 to 65% of medication related ER visits or readmissions are preventable

Adverse drug events

Adults 65 years and older account for more than 1/3 of ED visits related to adverse drug events. Top drug classes implicated are anticoagulants, diabetes agents and opioid analgesics. (JAMA 2016 – US data)

Many adverse drug events are not identified by ER physicians or coded appropriately. Thus the true incidence remains unknown.Kohl (2013), Roulet (2014)

Medications are increasing the complexity of care to seniors

• More diseases = increasing age = more medications

• More medications = • More side effects

• More drug interactions

• More errors / incidents

• More none adherence

• More adverse drug events

• More frailty, more falls

A shift from institutional care

http://www.homecareontario.ca/home-care-services/facts-figures/publiclyfundedhomecare

A shift from institutional care

Risk Mitigation

Caregivers:

• Elderly spouse

• Son or daughter

• Neighbour / Friend

• Government funded

• Private pay

The weight on their shoulders is a heavy load

Sometimes there is no caregiver

• Caregivers are expected to do what only trained professionals used to do

• Employed caregivers (PSWs, HCAs) - education of medication risks and standardized protocols are lacking

Medication Safety at Home

Adverse Drug Events – Doran study 2013

21.5% of cases had medications contributing to adverse events, including falls

Data was from 4 provinces

http://www.patientsafetyinstitute.ca/en/toolsResources/Research/commissionedResearch/SafetyatHome/Documents/Safety%20At%20Home%20Care.pdf

Medication Safety at Home

Medications contributing to falls

• Half of the falls that lead to injury and hospitalization happened at home• 35% of the hospitalization were related to hip fracture, and had longer LOS

https://www.cihi.ca/en/seniors_falls_info_en.pdf

http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2544881

Transitions in CareRisk point for medication errors and problems

https://www.ismp-canada.org/download/safetyBulletins/2014/ISMPCSB2014-8_MedicationIncidentsHomeCare.pdf

Medication Transition Failure Incident•Patient was admitted for an upper gastrointestinal bleed and possible stroke

• Computer discharge prescription was generated, signed, and given to the patient

• PPI prescribed was not covered by the provincial drug plan

• Patient decided to not pick it up due to cost

• Home visiting pharmacist, visiting 5 days after discharge

• Intervened to ensure receives necessary treatment

• Identified use of OTC NSAIDs, removed, recommended safer alternative

Transitions in Care – Hospital to HomeThe path is not straightforward

•68% of reported medication incidents in home care happened at this time

•14-95% of the time, people take medication differently than ordered by the hospital once home

•Up to 96% of people have actual medication related problems once home from hospital

Hospital to Home Toolkithttps://www.ismp-canada.org/transitions/

Quote says it all…….

“Right now we spend a lot of time trying to diagnose what is wrong with the patient, yet often

miss the fact that there is a medication-related problem. This means that patients often go home still on a medication which may be causing harm.”

Dr. Corinne Hohl, Associate Professor, Faculty of Emergency Medicine – University of British Columbia

The home health environment is ready.

Pharmacists need to step up and address medication safety.

Transition storiesDischarged home from hospital post DVT.

◦ Computerized Rx for Warfarin 4mg WRF Mitte: 1 month◦ Pharmacy dispensed Warfarin 4mg, Take 1 tablet Wednesday, Thursday, Friday

◦ Home visiting pharmacist, visited 3 days post discharge – no warfarin taken yet

◦ Intervened and clarified – Supposed to be Daily. WRF is an acronym in the hospital system

87 year old discharge home, post stroke. Ambulance transferred. Not mobile

◦ Wife went to pharmacy to get Rx filled. One of the Rx’s was for Warfarin 10mg daily.◦ Pharmacist told wife that blood tests need to be done

◦ Home visiting pharmacist, visited 7 days post discharge. Had been on high dose warfarin 10mg daily.

◦ No visit from lab, no visit from care coordinator yet, no lab requisition from hospital

◦ Contacted primary care provider – was not aware pt was home from hospital, had no idea he was responsible for warfarin monitoring

Patient Story – Mrs. JF• Patient referred by Assisted Living

Supervisor – falls, polypharmacy• 81 year old female• Caregiver for herself and her

husband with dementia• Fell 4 months ago, extensive

hospitalization due hip fracture• Presented a blister pack to home

visiting pharmacist

Patient Story – Mrs. JF

Initial interview

• Taking contents of blister pack (Imipramine 150mg! Qhs, Calcium, Vitamin D, Ramipril, HCTZ, Senokot)

Using a structured approach helps to get a clear picture

• Ask about different dosage forms

• Ask about indications that lead to OTC use:• Heartburn, headache/pain, constipation, diarrhea, cough/cold, vitamins,

sleep

• Ask about natural medicines

• Review of systems (head to toe)

Result:

• Uses Spiriva 18ug inhaled daily, salbutamol 100 mcg/puff prn for her COPD

• Acetaminophen ER 650mg po tid for arthritis pain

• Milk of magnesia prn

• Systane eye drops for dry eyes

• Gravol 50mg at bedtime to help her sleep

Buys any OTCs from another store – gets a better deal

Patient Story – Mrs. JFEnvironmental Scan / Clues

Opening of the cupboard, prompted more questions◦ What is that box?

◦ Are those your medications?

Saw the blood pressure machine on the coffee table

This revealed:

◦ Hydromorph Contin 3mg bid prn (takes on bad days) – dispensed 9 months ago

◦ Fosamax 70mg weekly (different pharmacy dispensed)

◦ Checks her blood pressure twice a week – results within target

Patient Story – Mrs. JF

Questions about adherence and disposal

“If you forget to take some pills, what do you do with them?”

Result:

• Mrs. JF went to grab the baggies full of the pills she or he husband had not taken – some sorted, some mixed

Let’s go back and talk about some of the issues that you brought up……

• Sleep is a problem due to excessive sweating

• Sweating even throughout the day is a problem

Patient Story – Mrs. JFWanted the pharmacy assessment because she wasn’t getting good answers from her pharmacist

◦ Her pharmacist was her son in law!

◦ Patient did not want to “rock the boat”, so asked me not to contact him

She had received a MedsCheck Annual already within 12 months, so was not billable for the MedsCheck at Home ($25 f/u + 2 POs = $55 for 4 hours of work + travel costs)

I presented options to meet her goals. Pt wishes were incorporated into letter to psychiatrist. They met, discussed, agreed on a plan to reduce imipramine.

Result: Health improved, less constipation, valued my role

Testimonial“It is not unusual for clients to have boxes or cupboards filled with bottles, blister packs with several pills in each pouch, several vitamin bottles, eye drops etc. Clients many times do not know what the medications are for.

Clients have prescriptions from multiple doctors and at times from different pharmacies. Clients will pick out pills from their blister pack because they are guessing maybe this pill is making them sick or maybe take out another pill because they don’t think they need it anymore. This can be a huge risk to clients.”

Kim Cowl, PSW Supervisor

Community and Home Assistance to Seniors

What is the evidence for a home visiting pharmacist?

Systematic / Qualitative Reviews

Godfrey, C et al 2013:

Homecare safety and medication management with older adults: a scoping review of the quantitative and qualitative evidence

• Benefits were reported by two experimental studies with the inclusion of a pharmacist to assess medications

Lang, A et al 2015:

Seniors managing multiple medications: using mixed methods to view the home care safety lens

• Absolute must read to have your eyes opened to how seniors and caregivers manage multiple medications in their home

MEDICATION MANAGEMENT PROGRAM – FRASER HEALTH BC

2005 INITIATED - ONGOING

Pharmacists were specially trained

Program developed, standardized assessment, metrics

Anyone can refer high risk elderly patients identified at transitions and some complex community based patients serviced – 1 or 2 visit model – centralized phone number

Net median cost reduction of $3047.43 per patient to health system – ROI was positive

Patient survey yielded high satisfaction and that the HVP should continue to be offered

https://www.ncbi.nlm.nih.gov/pubmed/22479013

https://www.ncbi.nlm.nih.gov/pubmed/24357867

MEDICATION MANAGEMENT SUPPORT SERVICES – CENTRAL CCAC ON

2008 - 2014

Trained and team based clinical pharmacists, hospital - partnered with local home care organization

Program developed, standardized assessment (database created), metrics – 2 visit model – 6 hrs of phm allocated

Care coordinators referred – transitions or complex community client

Consistent results over 5 years

Data for 2012-13: n= 1679

2-3 medication issues per patient (average), with >85% resolution

Reduced ER visits and falls, improved pain and same or better overall health (CHESS score)

99% of patients rated service as good or excellent

https://accreditation.ca/medication-management-support-services-mmss

DOVETAIL HEALTH – HOME BASED TRANSITIONS OF CARE

Post hospital discharge home visit

Specifically trained pharmacists

Intervention: reconcile and optimize medications, create medication care plan and share with patient and extended health care team

30% reduction in readmissions demonstrated over a 2 year period

https://www.ncbi.nlm.nih.gov/pubmed/22421517

PHARM2PHARM – HAWAII

TRANSITIONS OF CARE

Hospital pharmacist using criteria to identify high risk of MRPs

Trained community based consulting pharmacists

◦ Mandatory online module to be eligible http://pharmacy.uhh.hawaii.edu/ce/irdtp.php

Home visits or in a pharmacy with a trained consultant (patient preference)

264% ROI

https://youtu.be/zIjRkXj_48s

http://onlinelibrary.wiley.com/doi/10.1111/jgs.14518/full

MINNESOTA VISITING NURSING AGENCY ADDS A PHM TO THE TEAM

Partnered with a University to have access to Clinical Pharmacists

Standardized training, policy and procedures

On average, 4 MRPs/patient

706 visits to 570 clients

Preliminary review of 70 clients showed hospital and ED visit reduced by half

http://alliedhealth.ceconnection.com/files/TheRoleofaPharmacistontheHomeCareTeamACollaborativeModelBetweenaCollegeofPharmacyandaVisitingNurse-1415380776114.pdf

SUPPORTIVE HOUSING – ONTARIOWAITE N, MACKEIGAN L ET AL2007 PILOT

2007 pilot, consultant pharmacists, referred by HCPs, supervisors or pt

100 patients in seniors supportive housing. Had home visit, plus f/u home visit if required or telephone f/u

On average 8 Rx meds, 2 non-Rx

Phm identified 2.5 MRP per patient

67% of recommendations were adopted

Averaged 3.9 hrs of pharmacist time

http://journals.sagepub.com/doi/abs/10.1177/171516350714000224

MEDSCHECK AT HOME

JOHN PAPASTERGIOU PHARMACY LIMITED

Phms received training –standardized forms and intake

Patients identified by pharmacy –using weekly compliance packs or having home delivery

Pharmacist and student or intern did home visit

43 patients, average 1.4 MRPs (range 0 - 4) – 40% noncompliance

Removed 66 medications from home

Lack of followup being barrier

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3676215/

MEDSCHECK AT HOME

HOME CARE RX INC.

Certified Geriatric Consultant Pharmacists, experienced in home visits, transitions of care and falls, standardized process

Referrals from Geriatric Outreach, GEM RNs, CCACs, Assisted Living Supervisors – pts with actual medication management issues

95 patients home visit (9 month period)

Average of 2.7 MRPs addressed (range 0-8)

86% of pts had problems that required Primary Care prescriber input, of which 88% engaged by responding back

Average phm time: 3 - 4 hours per patient case (including travel)

Average support time: 1 hr

Lack of follow-up being a barrier, insufficient funding and poor buy-in from some community pharmacists

Abstract pending

Learnings from the studies1. All pharmacists delivering care were formally trained, supported and

followed a systematic intervention protocol (with metrics)

2. The community pharmacist is a player, but introducing a consultant pharmacist (fresh set of eyes) yielded positive intervention

3. Transition of care programs with a pharmacist are cost effective (worth the investment) to the healthcare system

4. There are lots of currently undetected medication related problems with community based patients (otherwise, no issues would be identified at these home visits)

5. Metrics reported were inconsistent across the studies – need standardizing. Follow-up protocols are not consistent or non-existent

Opportunity awaits! If we can work together

Community Pharmacists• Sought out for advice – by home care nurses, coordinators, patients and families

• Involved with improving adherence – setting up compliance packages or simplifying, delivering

• Helping to clarify medication discrepancies after hospital discharge

• Dealing with drug coverage issues

• Continuing to offer excellence with accurate drug dispensing, drug interaction screening, intervention on prescribing errors and educating on proper use

Depending on others to identify patients with medication concerns

Often trying to solve problems without having the whole story

Siloed – their assessment is rarely shared back to the home health team

Medication Reviews in Ontario

https://ejournals.library.ualberta.ca/index.php/JPPS/article/viewFile/25546/19226

1% of ODB receipientsreceived at

home MedsCheck

My experience…..as a consultant pharmacist

• Gaps are apparent

• Medication safety is a problem (dispensing errors, dosing concerns, inappropriate medications)

• Intra-professional collaboration is lacking

• Lack of awareness of community support services

• Complacency (“They have always been on that”, “Since it was from the hospital, it must be right.”)

• Seniors on complex medication regimens require extra time and follow-up to ensure they are on optimized medication regimens (may need deprescribing

The patient thinks we are nurses because a pharmacist has never talked with them this way!

++ Medication Waste

Waste after 4 admissions to hospital over a 3 month period by 1 patient

Wholly complicated!

•The medication plan tailored to the patient is often absent

•Goals•Lifestyle•Learning style•Respect for autonomy

In addition….So many other changes

•Goals•Support system• Lifestyle•Mobility•Cognition,

memory•Disease states•Mental Health•Finances

Complex Seniors –Must always consider the Aging Body

As the body ages, medications are processed differently –this means that a new symptom may be due to an old medication

An older body changes drug:

Absorption

Distribution

Elimination

Metabolism

Snapshot of Pharmacist Services for Home Health patients

In Ontario (in addition to MedsCheck at Home – 1% of the eligible ODB population):

• Family Health Team pharmacists (some have pharmacists, some do home visits)

• Geriatric Specialty care teams – some have pharmacists

• Some regions (LHINs) – Only 3 of 14 regions have home care pharmacists (1-2 FTEs) for supporting complex patients

There is no defined model – inconsistent care across the province

Ontario Data –Pharmacists as direct care providers

Pharmacist care is not even counted.Despite a regulation change in 2009 that deemed Pharmacy as clinical service providershttps://www.ontario.ca/laws/regulation/r09250

Snapshot of Pharmacist Services for Home Health patients

Western Canada

• B.C. – dedicated pharmacist FTEs in some health regions (e.g., Fraser, Island Health)

• Saskatchewan – 2 FTEs in regional home care (Saskatoon) for complex clients, two regions have contracted to a single pharmacy to streamline nursing care for med management clients

• Manitoba – Winnipeg – 2 community pharmacies “free home visits with compliance packaging services”. Regional pharmacist for medication safety – home care is under the umbrella

•Alberta – Albert Health Services employs some pharmacists to offer assessment for complex home care clients

Visit the poster sessionHome Care Pharmacy Practice in Canada: A Survey of Services Provided, Remuneration, Barriers, and FacilitatorsSherilyn Houle, University of Waterloo

Linda MacKeigan, University of Toronto

Check it out for Facilitators and Barriers

Everyone is doing their own thing (or not doing anything)

None of us are connected

Consistent metrics are not being collected and analyzed, economic value needs to be measured

Characteristics of a home health pharmacist• Compassionate, empathetic, patient and kind

• Tolerant, non-judgmental, appreciative of cultural diversity

• Active listening skills, ability to identify non-verbal cues

• Skilled at interviewing and redirecting, trained in BPMH

• Flexible

• Expertise in seniors care, medication and falls

• Unbiased

• Access to options to meet the needs of the patient

• Awareness surrounding transition of care issues

• Likes to travel

• System focused, mitigate risks

Characteristics of a home health pharmacist

The pharmacist’s desire to help people has to overcome the appeal of having scheduled shifts in a predictable work environment

Home Environment:

• Cluttered

• Smelly and/or dirty

• Pets

• Remote

• Potentially dangerous (e.g., icy steps, schizophrenic child)

• Bed bugs, exposure to infectious disease (VRE, MRSA, C. Diff, Influenza)

Or it may be beautiful and you wish you could live there!

Ideal home health pharmacistHas the characteristics and expertise previously defined

Is integrated into the care team (system support), ability to access and share documentation – not in silos. Can liaise with community pharmacist

Uses a standardized, evidence supported approach, with appropriate tools, to meets the needs of patients

Supported to collect defined metrics

Sufficiently funded, based on the needs of patient (# visits cap – not always optimal)

Has leadership support, network of similar professionals

Depending on the patient the best pharmacist may be their community pharmacist or it may be a home care pharmacist

Options for care must exist

Pharmacists need support• Policy and procedures to develop• Safety protocol

• Infectious disease risks

• Administering in-home vaccinations

• Suspected elder abuse

• Travel reimbursement

• Bed bugs

• Medication Incident reporting

• Suspected fraud identified

• Workflow, forms

• Lack of engagement from primary care

• Community resources

• Privacy, confidentiality, data sharing agreements

• Pets, smokers

• Drug disposal

•Insurance coverage for pharmacists doing home visits –not well defined

•Pharmacist slips and falls, sustaining injury in someone’s house•Accused of stealing or causing harm to patient •Experiences a car accident on the way to see a client

Forward Thinking•Community pharmacist services will continue to meet the medication management needs of most home health patients and their caregivers, from the pharmacy, some through in-home assessment

•Specialized clinical pharmacists in each region should be employed / contracted to meet the needs of the complex home health patient -provincial or federal funding must be specifically allocated for this role

•Standardized models across each province are required, with metrics, communication, incident reporting, linkages with primary care, policy and procedures etc.

Budgets that are silo based will not see the ROI of this investment in home health pharmacists.

A regional cost savings /avoidance lens is required

Check your medication safety systems

Home health pharmacists can also support the team and lead medication safety initiatives

Use available tools to increase medication safely from ISMP Canada

Let’s go forward….Advocate for clinical pharmacist inclusion into the home health funding model

Work together with the team for the benefit of the patient care

Complexity in the home environment is increasing. Let’s start intervening effectively.

Pharmacists need to join the home health team.

Medication Safety at Home

Thank youlisasever@homecarerx.ca

www.homecarerx.ca