4/3/2018. C-MEDS: An Innovative Community Medication Safety Program for Seniors & Caregivers. Objectives. Background: Aging & Medication

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1 C-MEDS: An Innovative Community Medication Safety Program for Seniors & Caregivers Marsha Meyer, PharmD, BCGP, CGCM Director, Independence at Home, a SCAN community service Objectives At the conclusion of this presentation, participants will be able to: Describe 3 risk factors associated with medication mismanagement in older adults Identify 3 barriers family caregivers face in assisting an older adult with medication management Examine 2 goals related to self-efficacy in medication management that impact overall medication safety and health outcomes for older, community-dwelling older adults Review 3 best practices used to support safer medication use in older adults Background: Aging & Medication A given dose of a given medication produces a different, and sometimes unexpected response in an older adult compared to a younger patient of the same gender and similar body weight. As adults age, medication use increases 75% of those fill an average of 13 Rxs/yr 87% of those fill an average of 20 Rxs/yr

2 Changes with Aging Older Adults: May have developed (more) illnesses May have greater severity of disease Are predominantly female/have smaller body size May have altered nutritional status May have had previous drug reactions May be taking drugs with a narrow therapeutic index Have a lifetime of developing bad medication management habits Have a lifelong history of developing health beliefs What is Medication Use Really Like in the Community Setting? The Scope of the Problem 30% of hospital admissions of seniors are related to medications 2 Over 3 million older adults are admitted to nursing homes due to medication-related problems 3 Up to 74% of medications prescribed for older adults are inappropriate 4 2 Col N, Fanale JE, Kronholm P. The role of medication non-adherence and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med. 1990;150: Johnson, Bootman JL. Drug-related morbidity and mortality. A cost-of-illness model. Arch Intern Med. 1995;155(18): Stuck AE, Beers MH, Steiner A, et al. Inappropriate medication use in community-residing older persons. Arch Intern Med. 1994;154:

3 And It Will Only Become Bigger 46 million people > 65 years old today in the U.S. By 2060, it is projected that those > 65 will number 98 million Risk Factors That Set an Older Adult Up for Unsafe Med Use Living alone Increasing # of chronic conditions Polypharmacy & dose burden > 1 Prescriber Vision, physical impairment, loss in grip strength Changes in cognition, low health literacy Alcohol and Drug Use by Seniors Estimated 1.1million ER visits by adults 50 related to ADRs 5 25% involved CNS drugs Binge drinking in those 65 = 8.2% Illicit drug use higher in boomer generation than any other prior generation 2012 study found lifetime rate for illicit drug use in yo was 47.6% 5 Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration,

4 The Medicine Cabinet Medication Reconciliation 2 days post-hospital discharge 6 64% were taking at least 1 medication that was not ordered 73% were not using at least 1 medication as prescribed 32% not taking all medications ordered at discharge 6 Beers MH, Sliwkowski J, Brooks J. Compliance with medication orders among the elderly after hospital discharge. Hosp Form 1992;27(7): CMS- Medicare Part D MTM Services 2012: only 11% of all Part D beneficiaries were part of an MTM program : only 1% of all Part D enrollees received a CMR : because of varying eligibility criteria for MTM services used by plans, enrollment in an MTM program varies between 0.2% and 57% of Medicare beneficiaries

5 The Role of Caregiver Family Caregivers 9 They are adult children, spouses, other relatives, friends/neighbors 46% of family caregivers perform medical/nursing tasks for a care recipient with multiple physical and cognitive conditions Approximately 43.5 million caregivers have provided unpaid care to an adult or child in the last 12 months 10 9 AARP (2012) Home Alone: Family Caregivers Providing Complex Chronic Care. 10 National Alliance for Caregiving and AARP (2015 ). Caregiving in the US Caregiver Training in Medication Management Family Caregivers 11 78% manage medications 60% report learning how to manage medications on their own 47% said they NEVER received training from any source 11 AARP (2012) Home Alone: Family Caregivers Providing Complex Chronic Care. Caregiver Barriers to Service Family Caregivers Spousal caregivers are at risk for the same deficits in cognition, physical impairments, literacy and language congruence as tcare recipient Paid Caregivers 12 60% in a recent study could not fill a pill box correctly 1/3 had difficulty reading and understanding health information 12 Linquist LA, Jain N, Tam K, et al. Inadequate health literacy among paid caregivers of seniors. J Gen Intern Med May 26(5):

6 The Creation of C-MEDS Addresses the lack of community-based in-home medication support to seniors & caregivers despite the overwhelming need to increase medication safety Pilot program to identify barriers to safe medication use Provide brief, patient-centered interventions to seniors & caregivers Supplement, not supplant existing medication services & resources (Avoid duplication of service) Partnership = Older Adult/Caregiver + C-MEDS team C-MEDS Service provided to the community at large Adults 55 yo; Caregivers to adults 55 yo No income, disability or insurance requirements English & Spanish Los Angeles County & Orange County In-home IDT of geriatric experts (pharmacists, nurses, technicians, coaches) > medication case management No cost to recipients C-MEDS Program Goals Identify and resolve barriers to safe medication use Increase self-efficacy and skills in medication management by older adults & caregivers Increase knowledge about medications Increase positive outcomes associated with medication use Increase coordination of care Increase medication adherence Increase access to medications 6

7 Staffing & Service Delivery: Medication Case Management Assessment Older Adult & Caregiver Referral > Phone screening > Home visit > Barriers to Safe Medication Use Readiness to participate Medication Review Medi-Cog (cognition, literacy, Brief falls risk- home walk through numeracy) MedAdhIR-ST (adherence risk) Medication storage MUSE (self-efficacy) Targeted pill count NIDA brief drug screen Illness & disability observation Access to medications MRP screener The Medication Use System Prescribing Transcribing Dispensing Administering Monitoring 7

8 Who Received Services in 2017? SAMPLE (n=104) Age: 72 years ± 8.5 years Gender: 67% female Last six months: 43% had a fall 53% unplanned ER/hospital admit Average no. of health conditions: 5.3 ± 2.3 Our Typical Client Assessment: What We Found n=104 8

9 Medication Safety as the Core Medication safety program- Not just focusing on adherence Medication knowledge low On average, 20.6 MRPs per client Interventions Referral > Phone screening > Home visit > Barriers to Safe Medication Use > Interventions n =104 Evaluation & Outcomes Referral > Phone screening > Home visit > Barriers to Safe Medication Use> Interventions > Outcomes Pre-, Post- measures; satisfaction scores Pilot study-no control or comparison group Early findings demonstrate diverse, older community-dwelling individuals have significant medication-related problems that require pharmacist intervention Literacy, knowledge and cognition related medications are significant problems Interventions are most successful when patient & caregivers are receptive to receiving help & instruction in medication management 9

10 Meet Lucy 77 years old Lives alone; grandson visits Ambulatory Spanish = preferred language Hispanic Completed High School Worked at Hughes Aircraft x 25 yrs Has Medicare Meet Lucy Identifies stroke, dyslipidemia, ESRD, HTN, OP, RA, chronic non-cancer pain, fainting/dizzy Uses cane/walker 4 falls in last 6 months, bruises & 1 overnight hospitalization Never misses an MD appt No RPh/other in-home visits What medication safety risk factors does Lucy have? 10

11 Medications Levothyroxine 112 mcg QD Hydrocodone/APAP 10/325-1 tablet 5 times a day PRN pain Duloxetine 20 mg QD Vit B mcg QD HCTZ 12.5 mg QD (takes at night Vit D iu QD because she is gone a lot during the day) Pravastatin 40 mg QHS Meclizine 25 mg QD PRN Alprazolam 0.25mg QD prn Voltaren Gel 1% topically PRN anxiety or insomnia (takes BID PRN for anxiety & insomnia) Immunizations- no tetanus or pneumonia Allergy- codeine = rash Prescription labels in English; Has auto refills & mail order What medication issues does Lucy have? Lucy s Assessment: Overview MedAdhIR-ST 6/13 ( 2) Falls screenhome Yes- obstacles, small dog, no path lights, scatter rug, Medi-Cog 10/10 Med storage Mixed pills in bottles; medicine cabinet expired meds (narcotics, antibiotics) Ct readiness 3/3 Access to meds ok MUSE 28/32 NIDA negative Illness & disability observation Cane/walker (falls) RA- grip & strength Targeted pill count (pravastatin) 7% 21 medication-related problems detected 11

12 Lucy s Medication Management Goals Lucy s: Help her remember to take meds on time What to do if she misses a dose C-MEDS: Reduce falls risk Increase adherence Improve medication storage Increase self-efficacy in medication management Increase prevention activities Interventions Patient partnership- used MAPs Identify need for caregiver assistance if low cognition Education Prescriber consultations Home safety recommendations First responder aids Adherence tools & training Self-efficacy & coaching Medication monitoring Pharmacist consultations- language, delivery Medicine cabinet safety Community referrals 12

13 Lucy s Outcomes Program start Program exit MUSE 28/32 32/32 MedAdhIR-ST 6/13 1/13 Pravastatin 7% 85% pill count Total Cholest Falls in 6 months prior to svc 4 0 during service Immunizations Missing Up-to-date Now I know how to ask the pharmacist questions. Before I had no confidence to speak to him. Now I won t walk out without the information I need. Lessons Learned in Year 1 Older adult challenges: Low health literacy Impaired cognition Vision & hearing difficulties 47% required assistance of a caregiver to overcome these deficits in med management Challenges to success: Patient reluctance to accept their need for assistance in medication management Caregiver lack of engagement 13

14 Thank You! Speaker Contact Information: Marsha Meyer, PharmD, BCGP, CGCM Independence at Home, a SCAN community Service Phone: (562) mmeyer@scanhealthplan.com 14