Interventions
Background & History
In 1997, the John A. Hartford Foundation provided funding for a medication management intervention project, which was conducted by investigators at Vanderbilt University in conjunction with the Visiting Nurse Association of Los Angeles (VNA) and the Visiting Nurse Service of New York (VNS). The project team first surveyed medication use among Medicare patients who received skilled home health care between 1996 and 1998 from the VNA or the VNS, two of the largest urban home health care agencies in the U.S. at the time.
Prevalence of Medication Problems in Home Health
The proportion of home health patients with a possible medication error was high; of the 6,718 patients included in the demonstration project, 19% had at least one potential medication error according to Home Health criteria developed by an expert panel10 and 17% had at least one medication error according to the Beers' criteria.11 When both sets of criteria were considered, 30% of patients had a potential medication error.9
Effectiveness in Home Health – the Randomized, Controlled Trial
The team undertook a randomized, controlled trial of an intervention to improve medication use among the elderly patients of these two home health agencies. The total sample was comprised of 317 patients with one or more of 13 medication problems. Follow-up interviews were completed for 259 patients (81% intervention subjects, 82% control subjects). The intervention - the Medication Management Model - consisted of advice from a consultant pharmacist to the attending nurse based on guidelines developed for this demonstration project. If appropriate, the nurse or pharmacist would bring the identified problem to the physician's attention.
The trial demonstrated that medication errors can be avoided or remedied and prescribing practices can be improved in this vulnerable population. Medication use improved in 50% of intervention patients, compared to 38% of controls (p=.05). Improvement was greatest for therapeutic duplication (24% vs. 71%, p=.003), cardiovascular problems (18% vs. 55%, p=.02) and problems associated with antipsychotic use (29% vs. 67%, p=.05). These findings are especially compelling because the demonstration project used a randomized control design, the gold standard for research trials.
Adaptation for Care Management Programs – AoA Evidence-Based Program
The original program to improve medication use was designed for Medicare-certified home health agencies providing in-home nursing and rehabilitation services to patients aged 65+. Determined to make the intervention more broadly available, Partners in Care (Partners), funded by the John A. Hartford Foundation, disseminated the intervention by providing technical assistance to additional home health agencies of diverse types across the country. The model was then translated from the home health setting and tested in three Southern California Medicaid waiver sites as part of a national Evidence-Based Prevention effort led by the US Administration on Aging (AoA). To make the medication management model even more accessible to those serving vulnerable elders, Partners adapted the program for implementation by care management entities. The new model, called the Medication Management Improvement System (MMIS) is currently being disseminated widely in California’s 1915(c) Medicaid waiver programs for elders, called the Multipurpose Senior Services Program (MSSP), and also to waiver programs throughout the US, under a new grant from the John A. Hartford Foundation.
References
1. Lazarou J, Pomeranz BH, Corey PN. Incidence of Adverse Drug Reactions in Hospitalized Patients: A Meta-Analysis of Prospective Studies. Journal of the American Medical Association 1998; 279:1200-5.
2. Feinberg JL. Ensuring Appropriate, Effective, and Safe Medication Use for Older People. Generations 2001;5:5-7.
3. Johnson JA, Bootman JL. Drug-Related Morbidity and Mortality: A Cost-Of-Illness Model. Archives of Internal Medicine 1995; 155:1949-56.
4. Bootman JL, Harrison DL, Cox E. The Healthcare Cost of Drug-Related Morbidity and Mortality in Nursing Facilities. Archives of Internal Medicine 1997; 157:2089-96.
5. American Society of Consultant Pharmacists. Dear Abby Response. e-mail communication, April 3, 2001.
6. Perry DP, Webster RT. Medication-Related Problems in Aging: Implications for Professionals and Policy Makers. Generations 2001;5:28-35.
7. Beers MH. Age-Related Changes as a Risk Factor for Medication-Related Problems. Generations 2001;4:22-27.
8. Atkin PA, Veith PC, Veith EM, Ogle SJ. The Epidemiology of Serious Adverse Drug Reactions among the Elderly. Drugs & Aging 1999;14:141-152.
9. Meredith S, Feldman P, Frey D, Hall K, Arnold K, Brown NH, Ray WA. Possible Medication Errors in Home Health Care. Submitted for review to Annals of Internal Medicine
10. Brown NJ, Griffin MR, Ray WA, Meredith S. Beers MH, Marren J, et al. A model for improving medication use in home health care patients. J Am Pharm. Assoc. 1998; 38:696-702.
11. Beers, MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. Arch Intern Med 1997; 157:1531-6.