Verify medication lists to improve outcomes

Oral medication management real challenge

With the Centers for Medicare & Medicaid Services (CMS) emphasizing the reduction of hospital readmissions as one way to cut the overall cost of health care for Medicare patients, home health agency managers have evaluated different ways to improve this outcome for their agencies.

While there are many strategies that work for different agencies, improving patients' medication management is a strategy used by 59% of participants in the recent National Home Health Hospitalization Reduction Study, points out Diana Hildebrand, RN, BS, CPHQ, project coordinator at TMF Health Quality Institute in Austin, TX.

"With the shortage of family caregivers and the shortage of money to hire caregivers, it is important for home health agencies to promote patient self-management of oral medications," she says. Not only does proper use of oral medications improve the patient's medical condition, but it improves the overall quality of life for the patient, she adds.

Improvement in the patient's ability to manage oral medications has been a part of the data collected for and reported on the CMS Home Health Compare web site as part of a home health agency's public record. Most home health managers expect this outcome to become part of the pay-for-performance program that will be implemented by CMS, says Hildebrand, adding that home health nurses face many challenges with improvement of this outcome. But it can be done, she notes.

"A nurse may start the admission visit with a list of medications provided by the referring hospital but it often does not match the full list of medications used by the patient," says Hildebrand.

Because older home health patients often take a number of medications, it is important to verify the list as soon as possible and look for medications that may interact with each other or medications that are duplicates of each other, she suggests.

"If possible, a home health agency representative should visit a patient before discharge from the hospital to begin developing an accurate list of medications," she says. "A home health nurse's ability to visit the patient before discharge will depend on the relationship with the hospital and the hospital's interpretation of HIPAA privacy rules."

EMR helps ID interactions

Building an accurate list early in the patient's care is important because it gives nurses time to find duplicate prescriptions and potential interactions, says Lisa Sprinkel, RN, BA, MSN, executive director of home health and hospice for Carilion Home Care Services in Roanoke, VA. "We use an electronic medical records [EMR] system that automatically checks for drug-to-drug and drug-to-food interactions when a nurse enters a new drug into the patient's chart," she explains. When the software detects an interaction, the nurse prints the information and faxes it to the physician for his or her review.

When the system was first introduced, physicians' reactions varied, Sprinkel says. "We had some physicians who appreciated the information and the fact that our nurses were reviewing the medications closely, and we had other physicians who thought it was a waste of time."

Even though there were some skeptics, Sprinkel's agency continues to use the system because it saves nurses' time as they can tailor medication evaluations to the patient and it provides documentation for the physicians.

"There is evidence that drugs affect the elderly differently from younger people," says Sprinkel. "An older person's decreasing liver function means that the body does not metabolize medications in the same way." Her agency uses Beers Criteria to evaluate medications for interactions as well as increased risks to older patients.

Education of Sprinkel's staff and resources such as the EMR software and Beers Criteria, help her nurses partner with physicians to become proactive in their efforts to reduce the risk of medication-associated adverse events, she says.

Pharmacists help organize medications

Other obstacles home health nurses must overcome when developing an accurate medication list for their patients are usually related to the patient's age, the number of medications used, and the ability to double-check interactions.

• Patients use multiple pharmacies.

"Some patients may fill a prescription at the pharmacy close to a physician's office after one visit, then fill another prescription close to home another time," Hildebrand points out. "Some prescriptions may be filled at a pharmacy close to a family member's workplace or home because it is more convenient for them." When multiple pharmacies are used to fill different prescriptions, you lose the benefit of a pharmacist who can detect potential interactions or duplicate medications, she says.

When a patient is using between 20 and 30 medications at one time, not only does the risk of potential interactions increase, but the schedule for taking medications becomes very complicated, says Hildebrand. "A patient takes some medications twice a day, other medications three times a day, some medications with food, and others without food; it is overwhelming for most patients to manage," she says. A home health nurse should help the patient and the family caregivers identify one pharmacy to use for all prescriptions so that the pharmacist can serve as an extra checkpoint for interactions and duplicates.

Another service that many pharmacists will provide is special packaging to help patients know when to take medications. "Pharmacists can fill the prescriptions in blister packs that designate morning, afternoon, and evening medications," Hildebrand says.

• Multiple physicians prescribe medications.

"There is a big push now to simply medicate a patient to control different symptoms or conditions," Hildebrand points out. Unfortunately, with a patient who sees multiple physicians for different conditions, one physician may not be aware of other medications the patient is taking. "Not only does this increase the risk of interactions, but research has shown that once you take more than five to eight different medications, you may be producing disease rather than treating anything," she adds.

In this case, it is important that communication between the hospital or other referral source, the physician, and the home health nurse begin as soon as the referral is made. Not only should the list be verified upon the patient's admission to home health, but it also should be updated every time the patient makes another visit to the physician or other health care provider, says Hildebrand. This may mean that at every visit, the nurse should ask the patient or the family caregiver if there have been any physician visits or calls to a physician that resulted in a change in medication, she adds.

In addition to evaluating the new medication's potential risk for interaction with other medications, the nurse needs to determine if this is a replacement medication for another or an additional medication, because patients don't always understand if the physician intends for them to stop taking a previous medication when the new medication is prescribed, she says.

• Patients hold on to "old" prescriptions.

Even when patients understand that they should stop taking a current medication, they don't always throw it away, points out Hildebrand. "They will hold on to the medication just in case they need it again, even when it is outdated," she says.

Not only is using outdated medication unwise, but having old medicine around enables the patient to self-medicate without knowing about potential risks, Hildebrand adds. In these cases, it is important to make sure patients and their family members know to throw away old medications to prevent accidental interactions.

While there is no simple, one-step method to improve oral medication management, it is worth the time and effort a home health manager spends on the outcome improvement, says Hildebrand. "Improvement of this outcome is not only important to the agency's ability to perform under a pay-for-performance system, but it is important to the overall quality of life for the patient."