Transcript No Slide Title

A Community-Based Medication
Management Intervention
Dennee Frey, PharmD
Partners in Care Foundation, San Fernando, CA
Kate Wilber, PhD
Gretchen Alkema, LCSW, PhD Candidate
University of Southern California, Los Angeles, CA
ASA/NCOA Conference, Anaheim, CA, March 2006
Session Objectives
1) Describe the Community Based Medication Intervention
including the role of care managers.
2) Identify lessons learned including some successes and
challenges to implementing a new intervention in existing
care management programs.
3) Discuss the tension between implementation fidelity and
adaptation in applied settings.

Some results of the program’s evaluation will be presented
including the program’s impact to identify medication
problems for frail older adults, ie prevalence data.
ASA/NCOA Conference, Anaheim, CA, March 2006
What do we know about
medication errors?

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Medication errors can create costly and serious, even
catastrophic, health problems:

5th leading cause of death for older adults1

7,000 deaths per year due to adverse drug events1
Studies estimate up to 40% of community-dwelling
seniors have medication-related problems2
About 1/5 of community-dwelling elderly use at least 1 of 33
drugs considered potentially inappropriate 2
1.
Institute of Medicine. (1999) To err is human: Building a safer health system. Kohn, L., Corrigan, J., Donaldson, M.
(Eds.) National Academy Press, Washington D.C.
2.
Zhan C, Sangl J, Bierman AS et al. Potentially inappropriate medication use in the community-dwelling elderly:
findings from the 1996 Medical Expenditure Panel Survey. JAMA. 2001; 286:2823-9.
ASA/NCOA Conference, Anaheim, CA, March 2006
Medication Management Intervention

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Partners in Care Foundation, San Fernando, CA, is conducting
a 3-year U.S. Administration on Aging (AoA) funded study to
apply a previously tested evidence-based Medication
Management Model to MSSP programs first in Los Angeles
County and then disseminate the program statewide.
The goal of our Medication Model is to identify, prevent, and
resolve medication errors among community-dwelling high-risk
seniors receiving Medicaid waiver care management services
ASA/NCOA Conference, Anaheim, CA, March 2006
Project Collaborators
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Multipurpose Senior Services Programs (MSSPs)
Partners In Care and Senior Care Network
Evaluators: Kate Wilber, PhD & Gretchen Alkema,
PhD Candidate, USC Andrus School of Gerontology
LA City Department of Aging AAA
LA County AAA
Others: Healthcare Partner, The Huntington Hospital,
Pasadena, CA; UCLA School of Medicine and USC
School of Pharmacy
ASA/NCOA Conference, Anaheim, CA, March 2006
Evidence-based Project Origins

Funded by John A. Hartford Foundation, Inc. in mid-90s
 Multiphase study to identify the prevalence of medication
errors and improve medication management among
Medicare beneficiaries receiving home health services.
 Developed by Vanderbilt University researchers & the
Visiting Nurse Assoc-LA (now Partners) and Visiting Nurse
Services, NYC
 To test the efficacy of Medication Management Model in
home health agencies the team undertook a randomized,
controlled trial intervention to improve medication use
 The Model uses a pharmacist-centered intervention to
identify & resolve medication errors
ASA/NCOA Conference, Anaheim, CA, March 2006
Results of Evidence-based Study

Results :
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17% had medication errors using Home Health criteria developed for
the study
Medication use improved in 50% of intervention patients,
compared to 38% of controls (p=.05).
Improvement was greatest for therapeutic duplication (71% vs
24% p=.003)
Cardiovascular problems (55% vs 18%, p=.02)
Conclusion:
 The trial demonstrated that medication errors can be avoided
and prescribing practices can be improved in the geriatric
population.
ASA/NCOA Conference, Anaheim, CA, March 2006
Adaptation of Model Program

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Adapted the previously tested evidence-based home health
care Model to the community care management setting
Implemented intervention in 3 MediCal/Medicare waiver
programs(MSSPs) serving low income, high risk seniors living
in diverse areas of Los Angeles
ASA/NCOA Conference, Anaheim, CA, March 2006
Overview of AoA Priority Population
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MSSP Care Managers are nurses and social workers who
conduct health and psychosocial assessments.
MSSP arranges for in-home services for frail seniors to delay or
prevent nursing home placement
Core Functions typically performed in care management:
 Outreach
Screening and Intake
 Comprehensive assessment
Care Planning
 Service Arrangement
Monitoring
 Reassessment
ASA/NCOA Conference, Anaheim, CA, March 2006
Program Features
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The Model uses guidelines established by an expert panel for
resolving high-risk medication problems among home health
patients:
 unnecessary therapeutic duplication
 cardiovascular medication problems
 use of psychotropic drugs in patients with a reported
recent fall and/or confusion
 use of non-steroidal anti-inflammatory drugs (NSAID) in
patients at high risk of peptic ulcer complications.
A consultant pharmacist assists care managers to assess and
resolve potential medication problems.
Computerized medication screening and alert system
ASA/NCOA Conference, Anaheim, CA, March 2006
Evaluation
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Process Evaluation monitored outcomes of translating evidence
based research into care management practice.
 Observation of trainings & care conferences
 Logic Model tracking procedural issues
Impact Evaluation looks at the following participant outcomes:
 # of clients screened
 # and type of medication errors
 Type of pharmacist recommendations
 Outcomes of recommendations
ASA/NCOA Conference, Anaheim, CA, March 2006
Sample Characteristics (N=615)
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Data collected from 6/2004-12/2005
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615 clients screened in 3 LA County MSSP sites
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Average age ~ 80 years (SD=7.76); 80% female
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53% widowed; 20% married; 13% divorced
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42% live alone
ASA/NCOA Conference, Anaheim, CA, March 2006
Race/Ethnicity (N=615)
50%
39%
40%
30%
24%
24%
20%
8%
10%
5%
0%
Caucasian
AfricanAmerican
Latino/a
Asian/PI
ASA/NCOA Conference, Anaheim, CA, March 2006
Other
Language Preference (N=615)
Spanish, 22%
Arm enian, 6%
English, 58%
Other (e.g.,
Chinese,
Tagalog,
Farsi), 8%
ASA/NCOA Conference, Anaheim, CA, March 2006
Health Status
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Hospitalization, SNF, or ER in Last Year? ~ 38% yes
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Average # of Medications ~ 8.76 (SD=3.7)
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Falls in Last 3 Months ~ 22%
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Dizziness ~ 27%
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Confusion ~ 31%
ASA/NCOA Conference, Anaheim, CA, March 2006
Site Differences – Race/Ethnicity
80.0%
60.0%
Site #1
(N=216)
40.0%
Site #2
(N=283)
Site #3
(N=126)
20.0%
0.0%
Caucasian
AfricanAmerican
Latino/a
Asian/PI
ASA/NCOA Conference, Anaheim, CA, March 2006
Other
Site Differences – CM Type (p<.001)
100.0%
89.7%
80.0%
Site #1
(N=216)
64.3%
60.0%
51.9%
48.1%
Site #2
(N=283)
35.7%
40.0%
Site #3
(N=126)
20.0%
10.3%
0.0%
Social Worker
Nurse
ASA/NCOA Conference, Anaheim, CA, March 2006
Site Differences – Lives Alone (p=.019)
60.0%
48.7%
40.0%
37.3%
34.7%
20.0%
0.0%
Site #1 (N=216)
Site #2 (N=283)
ASA/NCOA Conference, Anaheim, CA, March 2006
Site #3 (N=126)
Site Differences – 9+ Medications (p=.030)
80.0%
57.9%
60.0%
51.3%
43.5%
40.0%
20.0%
0.0%
Site #1 (N=216)
Site #2 (N=283)
ASA/NCOA Conference, Anaheim, CA, March 2006
Site #3 (N=126)
Medication Problem Prevalence
20%
17.6%
15%
12.7%
11.9%
MSSP
10%
6.9%
5%
4.0%
Home Health
6.4%
4.7%4.3%
0%
Therapeutic
Duplication***
Inappropriate Inappropriate
Cardiac
Psychotropic
NSAIDs***
Problems
Meds*** Conference, Anaheim, CA, March 2006
ASA/NCOA
Medication Problem Prevalence (N=615)
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Average # of medication problems ~ .53 (SD=.82)
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37.5% with at least 1 medication problem
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19% in original Home Health sample
12% with 2+ problems; 3% with 3+ problems
ASA/NCOA Conference, Anaheim, CA, March 2006
Medication Problem Prevalence
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Higher # of medications positively related to:
(p<.001)
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Any medication problem
Therapeutic duplication
Inappropriate psychotropic medication
Total # of medication problems
Clients w/ 9+ medications have 2x greater odds of
medication-related problems that those with under 9
meds
ASA/NCOA Conference, Anaheim, CA, March 2006
Lessons Learned
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MSSP frail elders seem at especially high risk for errors
Overall they have a higher prevalence of most
medication problems than original Home Health study
Based on this, there is a need to improve medication
management in this population.
A computerized medication risk assessment alert system
can assist care managers to identify therapeutic
duplication
ASA/NCOA Conference, Anaheim, CA, March 2006
Lessons Learned: Fidelity Issues

MSSP is a hybrid social/medical care management
program, presenting challenges in replicating the
Medication Intervention, eg scope of practice issues
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Clinical issues, eg cardiac assessment and follow-up
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Future: Modify, simplify and focus program materials
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Readiness assessment is essential before site
implementation
ASA/NCOA Conference, Anaheim, CA, March 2006
What do participants say?
“The pharmacist I spoke to
was very helpful in sorting
out my medications.”
“I was on too many
medications and didn’t
know what they were for.
I don’t have to worry
about that any longer.”
ASA/NCOA Conference, Anaheim, CA, March 2006
Contact Information
Dennee Frey, PharmD
Project Director
Partners in Care Foundation
732 Mott Street, Suite 150
San Fernando, CA 91340
818-837-3775, ext. 136
[email protected]
Kate Wilber, PhD
Gretchen Alkema, PhD Candidate
Project Evaluator
University of Southern California
Andrus Gerontology Center
3715 McClintock Ave.
Los Angeles, CA 90089-0191
213-740-1736
[email protected]
ASA/NCOA Conference, Anaheim, CA, March 2006
Healthy Moves for Aging Well
Enhancing Physical Activity for Frail Elders
Changing Care Management Practice
Jennifer Wieckowski, MSG
June Simmons, LCSW, CEO
Mira Trufasiu, MSG
Partners in Care Foundation
Christy Nishita, PhD
Kate Wilber, PhD
USC Andrus Gerontology
ASA/NCOA Conference, Anaheim, CA, March 2006
Funders & Sponsors
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Originally funded by the John A. Hartford Foundation
Currently funded by:
• Archstone Foundation
• The California Endowment
• UniHealth Foundation
Sponsored by the AoA Evidence-based Prevention Initiative
Guided by the National Council on the Aging
Evaluated by the USC Andrus Gerontology School
ASA/NCOA Conference, Anaheim, CA, March 2006
Benefits of Physical Activity
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Reduces the Risk of Developing Chronic Diseases
Aids in the management of active problems such as
high blood pressure, diabetes, obesity and high
cholesterol
Improves the ability to function and stay
independent in the face of active problems like lung
disease or arthritis
Reduces symptoms of depression and pain
Improves balance and prevents falls
ASA/NCOA Conference, Anaheim, CA, March 2006
Evidence-Based Study (Rikli & Jones, 1999)
SENIOR FITNESS TEST
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Nationwide study conducted to establish normative
physical performance scores for community-residing
older adults
Ages 60 to 94
7,183 participants
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5,048 women & 2,135 men
267 sites
21 states
ASA/NCOA Conference, Anaheim, CA, March 2006
Implementation in
Care Management Practice
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Care Managers as Change Agents
Regular Interaction with Frail, Nursing Home
Certifiable Older Adults
Most effective vehicle for addressing physical
activity issues, but lack training in setting client
goals, fostering behavior change, and improving
physical activity
ASA/NCOA Conference, Anaheim, CA, March 2006
Pilot Results—Model Programs Project
76% Client Retention Rate
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4 Care Management Sites
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Senior Care Network at Huntington Hospital
Jewish Family Service
AltaMed Health Services Corporation
Partners in Care North
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Number of Clients = 49
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Average Age = 78 years
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Living Status =
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65.3% Living Alone
30.6% Living with Family
4.1% Living with Family & Caregiver
ASA/NCOA Conference, Anaheim, CA, March 2006
Healthy Moves Pilot
“WHAT WE LEARNED”
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The majority of clients were too frail to perform tests
according to protocol.
Care management staff was overwhelmed
Gathering valuable input from care managers, site leaders,
seniors, evaluation team and advisory team the program
evolved into…“HEALTHY MOVES FOR AGING WELL”
ASA/NCOA Conference, Anaheim, CA, March 2006
HOW DO THE MOVEMENTS
APPLY TO MY LIFE?
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Lifting/carrying laundry &
groceries
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Upper body endurance &
strength
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Pouring a drink from a carton
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Holding grandchildren
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Increases blood circulation
to manage/ prevent ankle
swelling
Arm Curl
Ankle Point
& Flex
Chair Stand
Step-In-Place
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Reduces fall risk
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Increases ability to lift toes to
avoid tripping on rugs, steps &
curbs
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Increases ankle flexibility
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Rising from a chair or toilet
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Getting in & out of the car
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Getting on & off public
transportation
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Strengthen lower legs
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Getting to toilet
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Shopping for groceries
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Walking outside to get ride

Getting the mail
ASA/NCOA Conference, Anaheim, CA, March 2006
Client Goal Setting
Holding
Grandchild
Rising From
a Chair or
Toilet
Getting
the Mail
Lifting Toes
to Avoid
Tripping
Doing Your
Own Grocery
Shopping
Pouring a
Drink From
a Carton
Your Goal
Walking
in the
Home
ASA/NCOA Conference, Anaheim, CA, March 2006
Behavior Change Education
Brief Negotiation Curriculum
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Teaches skills needed to incorporate physical activity
into clients’ daily routines
Trusts the natural change potential in every client
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Client self-assessment of readiness for change
How ready are you to consider increasing your physical activity?
0
1
Not Ready
2
3
4
5
6
7
8
Thinking About It
ASA/NCOA Conference, Anaheim, CA, March 2006
9
10
Ready
Exercise Coaches Monitor Progress
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Community volunteers & student interns
Are you doing your new movements? Which ones?
How many times a week? For how long each time?
Which movement is easiest/hardest?
Are you experiencing any discomfort?
Have you had any falls?
Rate the enthusiasm of client from 0-10
ASA/NCOA Conference, Anaheim, CA, March 2006
Protocol
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Care managers teach intervention
Volunteer Coaches monitor progress and reinforce
the change by phone
Care managers follow-up with client at monthly
phone calls and at a 3 month visit
ASA/NCOA Conference, Anaheim, CA, March 2006
2nd Generation of Healthy Moves
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4 MSSP Sites
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Jewish Family Service of Los Angeles- 700 clients
Partners in Care South Central Site- 400 clients
AltaMed Health Services Corporation- 603 clients
Senior Care Network at Huntington Hospital- 440 clients
ASA/NCOA Conference, Anaheim, CA, March 2006
Three Research Questions
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Does intervention change care manager behavior?
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Does intervention change client behavior?
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Focus Groups and Questionnaires
Acceptance, Adoption, Satisfaction, Behavior and System Change
Readiness to exercise
Client goal achievement
Maintenance of exercises without a coach
Does intervention improve client’s health outcomes?
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Pre and post-test design
Evaluating Pain, Depression, Falls, Fear of Falling, and Physical
Functioning
ASA/NCOA Conference, Anaheim, CA, March 2006
Preliminary Findings:
Client Behavior & Outcomes
ASA/NCOA Conference, Anaheim, CA, March 2006
Preliminary Findings
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264 participating clients (enrollment began 6/2005)
Average age: 80 years old
Languages: English, Spanish, Russian, Chinese,
Korean, Farsi
Examples of Client Goals:
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Rise from chair/toilet
Ambulate & transfer better
Walk outside to get ride
Improve general health
Goal Achievement Score- 6.23 out of 10
75% Very Likely to Continue Exercises
ASA/NCOA Conference, Anaheim, CA, March 2006
Number of Falls
Change in Number of Falls from Baseline to
Follow-up
1.00
0.80
0.60
0.40
0.36
0.12
0.20
0.00
Baseline
Follow-up
ASA/NCOA Conference, Anaheim, CA, March 2006
Pain Scale
0
1
2
3
4
5
6
7
8
9
10
Change in Level of Pain from Baseline to Followup
9.00
6.92
7.00
6.00
5.00
3.00
1.00
Baseline
Follow-up
ASA/NCOA Conference, Anaheim, CA, March 2006
Depression / Anxiety
Percent of Participants Who Experienced Some
Depression or Anxiety at Baseline and Follow-up
100.00%
80.00%
60.00%
54.50%
43.20%
40.00%
20.00%
0.00%
Baseline
ASA/NCOA Conference, Anaheim, CA, March 2006
Follow-up
Client Example—96 year old
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"I know that I am stronger. I count myself as doing
wonderful. I give myself praise because I'm doing a lot
better. I'm not afraid of falling anymore because I am a
lot stronger. -96 year old.
Pain decreased from 9 to 1
Fear of falling decreased
Endurance to perform step-in-place improved
•
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40 Seconds To 2 Minutes
Achieved goal to walk outside
“How likely will you continue without a coach?”
•
Client said, "I won't be able to stop."
ASA/NCOA Conference, Anaheim, CA, March 2006
Preliminary Findings: The Care
Manager Perspective
ASA/NCOA Conference, Anaheim, CA, March 2006
Initial Concerns With Participation
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Additional Workload
Extra Time Needed
Staff’s Level of Support for Program
Client Safety
ASA/NCOA Conference, Anaheim, CA, March 2006
Important Motivators
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Guest Speaker That Discussed Importance of
Physical Activity
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Recognition of Potential Benefits to Clients
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Improving their Professional Capacity
ASA/NCOA Conference, Anaheim, CA, March 2006
Satisfaction With Program
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Staff Very Satisfied With the Program’s Benefits
to the Client and Agency Itself
Majority Believed that the Volunteer Coaches
Were Very Important In Keeping Clients
Motivated
60% Stated that the Addition of the Program to
Their Current Caseload Was Manageable, the
Remainder Believed It Was Difficult
ASA/NCOA Conference, Anaheim, CA, March 2006
Sustainability of the Program
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Continued Concerns Because of Heavy Caseload and
the Extra Time Needed to Introduce Program
80% of Care Managers Agreed With the Following
Statements:
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“Providing safe exercises to frail elders should be a
part of a MSSP care managers' scope of practice”
“The use of MSSP care managers is an effective
approach to encouraging physical activity among MSSP
clients”.
ASA/NCOA Conference, Anaheim, CA, March 2006
Care Manager Recommendations
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“I feel the Healthy Moves program is very effective
how it is set up. Clients have said nothing but
positive things about the program.”
“They seem to want more sophisticated exercises.”
“A greater variety of exercises should be provided to
accommodate clients with different levels of
physical fitness.”
ASA/NCOA Conference, Anaheim, CA, March 2006
Challenges in Delivery System Change
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Liability & Concerns
Workload
Reinforcement of staff training
Social Worker Bias
 CM scope of practice
 CM resistance to change
ASA/NCOA Conference, Anaheim, CA, March 2006
Lessons Learned: Changing Care
Management Practice
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Changing practice standards & shifting staff
responsibilities almost always elicits a learning curve.
Intervention must fit practice environment- simple &
succinct
Changing behavior requires supervisory buy-in
Agencies must be “ready” to adopt a new innovation—
staff shortages complicate demands on staff
ASA/NCOA Conference, Anaheim, CA, March 2006
Lessons Learned Cont’d
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Joint planning with staff & supervisors identifies
valuable methods to create change (i.e. focus
groups, questionnaires)
Intervention must be marketed in terms of value to
staff
Client testimonials generate enthusiasm for adoption
Volunteer recruitment requires new partners &
innovations
ASA/NCOA Conference, Anaheim, CA, March 2006
Contact Information
Jennifer Wieckowski, MSG
Project Manager
Partners in Care Foundation
732 Mott Street, Suite 150
San Fernando, CA 91340
818-837-3775, ext. 115
[email protected]
www.picf.org
Christy Nishita, PhD
Post-Doctoral Research Associate
University of Southern California
Andrus Gerontology Center
Los Angeles, CA 90089-0191
[email protected]
ASA/NCOA Conference, Anaheim, CA, March 2006