Medication Management Support Services (MMSS) Aging at Home Mary Burello-Cordovado Senior Manager, Client Services, Special Projects March 3, 2010
Objectives • Update on Medication Management Support Services (MMSS) as an Aging at Home Strategy • Provide an overview of the project and case examples of success • How does MMSS keeps older adults healthy at home? • Review outcomes and demonstrate quality measures to date • Demonstrate how MMSS can reduce potential ED visits 2
Background • In June 2008, the Central LHIN approved the Medication Management Support Services (MMSS) project. • The organizations involved: • Central CCAC – Project Lead • SRT Med Staff • COTA Health now VHA Rehab Services • York Central Hospital • Southlake Regional Health Centre • New members: • St. Elizabeth Health Care • Acute care hospitals in Central LHIN 3
Central York CCAC SRT Med Central Sta f f Inc. hospital St. Physicians Elizabeth Client/ Health Caregiver Care Hospitals VHA Rehab Community Pharmacist 4
Seniors + Medications = ER visits? Seniors + Medications = ER visits? ADEs account for an estimated 10-17% of admissions to hospital involving elderly patients (Hayes et al, 2007), and it has been suggested that as many as 75% of these admissions could have been prevented if medications had been used appropriately (reviewed in Gallagher et al, 2007) 5 Adapted from Polypharmacy in the Frail Elderly (GiiC)
High Risk Issues • Canadian Study (CMAJ June 3, 2008 – ZED PJ et al) • 122 patients had medication-related admissions • 83 of these were deemed preventable* Most Com m on Medication Problem Adverse Drug Reaction 39.3% Non-adherence 27.9% * Improper Dose 12.3% Improper Drug Selection 11.4% Untreated Indication 9.0% 6
Value Stream Analysis: August 2008 • 3-day event with: • Project Partners • ISMP was in attendance as well as a representative from the Pharmacy Association • Staff from prior Scarborough CCAC project • Identified that existing processes show duplication of effort • Too many lists completed and not shared • Meds Check not well-known • Central CCAC clients would benefit from medication reconciliation 7
What is the Eligibility Criteria? • Mandatory Criteria • 65 years or older • Taking three (3) or more medications • Has one (1) or more chronic diseases • Valid OHIP; eligible for CCAC services • Resident of Central CCAC • One or more risks as identified in eligibility criteria (falls, frequent visits to ER/ hospitalizations, uncontrolled pain) 8
Medication Management Support Services • Phase 1: MMSS1 – Nursing • 2 visits in 30 day period • Phase 2: MMSS2 – Pharmacy • 2 visits in 30 day period • CCAC Case Manager/ Service Provider can recommend Phase 1 or Phase 2 of MMSS depending on complexity of client • Clients in Phase 1 can be referred to Phase 2 by the nurse provider or CCAC 9
How have the clients benefited? • Enables nurse and pharmacist to: • Create a complete and accurate inventory of all medications • Prescribed/ over-the-counter/ herbal • Review storage and organization of medications • Assess the appropriateness of medications • Assess client/ caregiver self-administration/ caregiver skill and methods 10
How have the clients benefited? • Determine any cognitive deficits which would prevent the client/ caregiver from safely administering medication • Determine any physical deficits which impede client/ caregiver ability to administer the prescribed medication • Reduced vision, decrease in manual dexterity • Compare the current medications with medications prescribed • Identify any discrepancies/ medication related problems • Bring it to the attention of the prescribing physician 11
What can the client expect? • The nurse or pharmacist completes and provides a medication schedule • After confirmation and discrepancies are resolved with the prescribing physician • Makes recommendations • The need for aides or cues • Blister pack/ Compliance packaging or dosette system, visual reminders • Make recommendations • Additional or increased services • Increased PSW hours for reminders, OT assessment, referral to a community support agency, nursing visits • Educate the client/ caregiver regarding medications, side-effects, dose, administration times, and procurement of medications • Storage • Copy of the schedule is then sent to the family physician 12
Medication Management Support Services “ W here Principles of Pharm acy Practice Converge” Albert Chaiet, R.Ph., B.Sc.Phm., M.Sc.Phm., M.B.A. Director, Pharmacy Services, York Central Hospital 13
Convergence • Standards of Practice • Pharmaceutical Care • Medication Reconciliation • CSHP 2015 14
Standards of Practice • Ontario College of Pharmacists • Canadian Society of Hospital Pharmacists 15
Pharmaceutical Care • Identifying and resolving potential or actual drug related problems • Care planning • Ethics of care • Duty of care 16
Medication Reconciliation • Accreditation Canada R.O.P.s • BPMH on admission • Reconciliation at transfer points including discharge 17
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C.S.H.P. 2015: Goal 2 • “Increase the extent to which pharmacists help individual non-hospitalized patients achieve the best use of medications” • Objective 2.3: In 85% of home care services, pharmacists will manage medication therapy for patients with complex and high-risk medication regimens, in collaboration with other members of the healthcare team” 19
A Pharmacist Home Visit … … … A Pharmacist Home Visit … • Can unlock the door to the problem • We can see exactly what the patient has at home (contrary to a list!) • Patient is comfortable in their surroundings • Minimal distractions • Environment scan to see how managing the medications • Pharmacists are very skilled at dealing with medication issues 20
Identifying limitations Identifying limitations • Physical • Cognitive • Accessibility • Adherence • Safety • Knowledge • Storage and Organization 21
Interventions for Disease Prevention or Interventions for Disease Prevention or Management Management • Indications are appropriately treated • Preventative medicine is used and Rx’d appropriately (e.g. Vitamin D, EC ASA) • Administration techniques appropriate • Disease exacerbation – knows the plan • When to use Nitroglycerin Spray • SOB – what puffer to have handy • Uncontrolled B.S. when sick 22
Medication Management Visit Means: Medication Management Visit Means: • Asking the patient for their desired goals from their medication • Educating • Acting as an advocate for the patient • Recommending professional services to benefit the patient Assess all com ponents of their m edications for: Safety, Simplicity and Correctness 23
Case Case Discharge from Hospital Discharge from Hospital • Direct referral to pharmacy • Direct referral to pharmacy • Client on blister pack system • Client on blister pack system • Blister pack filled according to D/ C rx rx • Blister pack filled according to D/ C • Community phm phm contacted hospital MD regarding contacted hospital MD regarding • Community insulin – – not on Rx not on Rx insulin • • Instructed to tell client to Instructed to tell client to f/ u f/ u with family MD with family MD • Client to see family MD in 5 days • Client to see family MD in 5 days 24
Pharmacist Home Visit Pharmacist Home Visit • • Had medication reconciliation form, labs and copy of D/ C rx Had medication reconciliation form, labs and copy of D/ C rx from hospital records from hospital records • First question they asked – – “ “ What about her insulin? What about her insulin?” ” • First question they asked • Hospital increased oral BS meds to control DM – – not not • Hospital increased oral BS meds to control DM knowing she used insulin at home knowing she used insulin at home • Family MD appt in 5 days. Been on oral regimen for last 3 • Family MD appt in 5 days. Been on oral regimen for last 3 weeks in hospital B.S. not too bad (assess urgency) weeks in hospital B.S. not too bad (assess urgency) 25
Pharmacist Home Visit Pharmacist Home Visit • Reviewed blister pack – – rx rx’ ’s s all correct from all correct from • Reviewed blister pack discharge Rx discharge Rx • Iron being given at breakfast (interacts with her • Iron being given at breakfast (interacts with her levothyroxine) and bedtime ) and bedtime levothyroxine • + + heartburn and upset stomach – – PPI switched PPI switched • + + heartburn and upset stomach at time of discharge, Metformin Metformin or Ferrous or Ferrous at time of discharge, gluconate could be contributing gluconate could be contributing • c/ o tingling in fingers • c/ o tingling in fingers • • Community phm Community phm helped chg helped chg Pariet Pariet to her normal to her normal PPI of Prevacid Prevacid and and chg chg’ ’d d timing of iron timing of iron PPI of 26
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