Solution Management: A New Standard for Care Management Programs

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Pharmaceutical Administration: Another Standard for Consideration Administration Programs. Sandy Atkins Venture Executive Mira Trufasiu Venture Director. Accomplices in Consideration Foundation . Los Angeles, CA Changing the state of human services Joint effort * Development * Sway

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Medicine Management: A New Standard for Care Management Programs Sandy Atkins Project Director Mira Trufasiu Project Manager

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Partners in Care Foundation Los Angeles, CA Changing the state of social insurance Collaboration * Innovation * Impact Design, create and pilot new projects that will fill in as replicable models of care

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The Importance of Evidence-based Programs National development. Tried models or intercessions that specifically address wellbeing dangers. "With our Evidence-Based Prevention Program, we are taking wellbeing advancement and malady counteractive action to another level and situating the maturing system as an across the country vehicle for making an interpretation of research into practice." - Josefina Carbonell, 2004

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Medication Management Project Purpose: Partners in Care is leading a multi-stage study to apply prove based medicine administration to Medicaid waiver mind administration programs in California and across the country. Recognize the commonness of potential prescription issues in high-hazard more seasoned grown-ups getting Medicaid waiver mind administration benefits at home. Enhance customer wellbeing and security by overseeing pharmaceuticals Evaluate customer and program-level results.

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Why Use Care Managers? Concentrated on keeping up wellbeing status, postponing standardization, and enhancing linkages with therapeutic & group assets Already gathering medicine and clinical data Visit slight, low-pay seniors in their homes Established compatibility with and think about their customers Linguistically and socially capable staff Knowledgeable of accessible assets

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Evolution of Medication Management Program Hartford Phase 1993-2003 HOME HEALTH AGENCY Vanderbilt Univ. randomized controlled trial to enhance solution utilize; created, tried, spread and received AOA Evidence-Based Prevention Initiative, 2003-2007 Community-Based Medication Intervention Model effective in Medicaid waiver programs Next Phase, 2006–2010, Hartford Foundation Taking meds administration statewide first then across the nation in care administration!

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Medication Management Project Rationale Patient Safety - Medication blunders are: Serious: At slightest 1.5 million preventable unfriendly medication occasions (ADEs) every year; 7,000 passings for each year because of ADEs. 1,3 Frequent: Up to 48% of group staying more seasoned grown-ups have prescription related issues 2 Costly: Drug-related horribleness and mortality for seniors surpasses $170 billion (incorporates healing facility and long haul mind confirmations) 2 Preventable: At minimum 25% of antagonistic medication occasions in mobile settings are preventable. Olmstead Act: Equity issue - Pharmacist audit compulsory for all SNF and prescription survey for ICF, ADHC Medicare Drug Act: MTM arrangement for high-chance seniors IOM (1999) To fail is human: Building a more secure wellbeing framework. Kohn, L., Corrigan, J., Donaldson, M. (Eds.) National Academy Press, Washington D.C. Zhan C, Sangl J, Bierman AS et al. Possibly improper prescription use in the group abiding elderly: discoveries from the 1996 Medical Expenditure Panel Survey. JAMA. 2001; 286:2823-9. IOM (2006) Preventing Medication Errors.

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Evidence-Based Origins Hartford/Vanderbilt Randomized Controlled Trial in Medicare home wellbeing patients matured 65+. Created by Visiting Nurse Assoc-LA (now Partners), Visiting Nurse Services, NYC & Vanderbilt University analysts Randomized, controlled trial demonstrated the adequacy of the Medication Management Model in home wellbeing organizations The model utilized a drug specialist focused intercession to recognize & resolve solution mistakes 19% had potential prescription blunders utilizing master board's criteria Medication utilize enhanced in half of mediation patients, compared to 38% of controls (p=.05) when a drug specialist helped homecare staff

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"Your condition has no manifestations or wellbeing dangers, however there is an extraordinary new pill for it."

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Medication Risk Assessment Screening RN mind directors gather customers' meds records and clinical markers Vital signs, falls, dazedness, unique disarray Med records are screened by an advisor drug specialist. Concentrate on the four most regular medicine mistakes: Unnecessary helpful duplication ; Cardiovascular solution issues identified with discombobulation, proceeded with hypertension, low circulatory strain, or low heartbeat; Falls, dazedness, or disarray perhaps brought on by improper psychotropic medications; Inappropriate utilization of non-steroidal calming drugs ( NSAIDs ) in those with hazard variables for peptic ulcer.

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Intervention – From Alerts to Action

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Role of the drug specialist Reviewed prescription rundown as indicated by study criteria Screened cautions to affirm genuine issues in light of conclusions, side effects, different pharmaceuticals, and so forth. Helped with complex cases, especially when there is a home security or incessant asset use issue; Communicated with a customer's MD(s) to demand re-assessment. Sometimes recognized other medicine related issues – outside of conventions.

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Population Characteristics: 615 customers screened at 3 Medicaid waiver locales in LA County 65+ certifiable for talented nursing office arrangement Dually qualified (Medicare & Medicaid) Average age: 81 (65-108) Female: 80% Hospitalization, SNF, or ER in a year ago? ~ 38% yes Falls in most recent 3 Months ~ 22% Dizziness ~ 27% Confusion ~ 31% Lived alone ~ 21% Mean # of solutions: 8.76 12+ meds – 22%

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Race/Ethnicity by Site (N=615)

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Evidence of Effectiveness 615 customers in 3 Medicaid waiver destinations were screened 49% (N=299) had potential drug issues. Record survey and conference with the customer drove the drug specialist to prescribe: Continue the pharmaceuticals - important for torment/manifestation control; Collect more data - crucial signs and other clinical pointers Verify measurement and recurrence with which the customer was taking the prescription and reexamine the solution list in like manner; or Change medicines or dose. 29% of the 615 customers had affirmed medicine issue - drug specialist suggested an adjustment in pharmaceuticals, including re-assessment by the doctor. 61% (N=118) of suggested changes were executed.

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49% of customers had no less than one potential pharmaceutical issue (N=299) 24.2% w/restorative duplication (N= 149) 14.3% w/improper psychotropic meds (N=88) 14.1% w/cardiovascular issues (N=87) 12.8% w/unseemly NSAIDs (N=79) Potential Medication Problems by Type

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# of potential issues increments with # of drugs taken *p<.05, **p<.01, ***p<.001

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Improvement after mediation

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Results: ~50% had no less than 1 potential solution issue Vs. 19% in unique home wellbeing test (HH) All issue sorts had no less than 2x commonness of HH The most astounding issue predominance was pointless helpful duplication Greatest indicator of issues: # of pharmaceuticals

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Waiver Staff Perspectives on Project Overall + reactions to mediation & interpretation Key contrasts Nurse/Social Worker viewpoints Experience with EBP execution Location of care directors

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CM Feedback on Project Benefits "Distinguish dangerous meds & duplication" "Educating customers or groups of potential symptoms" "Expanded instructing on meds, reactions, and restorative impact which is great practice in patient care" "As a social laborer I got to be distinctly mindful of potential risks of or entanglements of a few drugs; I now take a gander at all solutions my customers are taking"

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CM Feedback on Project Challenges "No or moderate reaction from the specialist. Numerous customers get a kick out of the chance to keep all meds including those they were taken off, making it extremely confounding. It can require a long investment to address a med issue" "A few customers have taken certain pharmaceuticals for so long that they were unwilling/dread to change" "Awkward tending to this issue with MDs ~ feel it is past my extent of practice"

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Conclusions High predominance of potential issues for those at hazard for organization recommends a requirement for more methodical drug administration in group based projects Those with affirmed solution issues profited from a prescription administration change mediation that incorporates a drug specialist counseling with care supervisors & doctors Care directors experienced fulfillment from affecting customer wellbeing and security by overseeing medicines

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Lessons Learned from Study Need for an automated pharmaceutical hazard appraisal and ready framework Hybrid nature of MSSP displayed challenges MD Communication Scope of Practice Clinical issues e.g. heart appraisal Agency availability is fundamental for achievement

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Indicators of Agency Readiness There must be a "felt need" A feeling of the significance and earnestness of the issue There must be a champion Pull others along, learn frameworks, tutor others, fill in for instance, and cheerlead when there are victories. There must be fundamental steadiness Resources saw as sufficient Staff turnover insignificant Recovery time since last enormous change

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Start little Champion & little group New enrollees just Changing consideration administration rehearse. Continuous preparing Staff guide each other Staff decision in plan alternatives Leadership underscores the significance of finish; Clear strategies and conventions Rewards, challenges, challenges Help with routine information section Use people group drug store assets innovatively. Drug store understudies under the supervision of their educator Local people group drug specialists that serve mind administration customers. Future – Part D Medication Therapy Management Best approaches to speak with doctors. Normally FAX Pharmacist, attendant, or care supervisor Implementation Experience

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Medication Management Tools Tracking and recording pharmaceutical alarms