Medication management requires holistic’ approach

How do drugs affect patients’ lives?

Good medication management of home health patients involves more than monitoring to ensure pills are being taken on schedule. In these days of complex illnesses and multidrug regimens, agencies need to learn how a patient copes with drug-taking routines, side effects, and the other consequences of medication. They also need to help patients work through the obstacles to good drug-taking habits and advocate for patients with physicians who may not realize the drug burden a patient is under.

"It’s really about incorporating the medication into the patients’ lifestyle," says Deborah Wendt, RN, PhD, CS, associate professor of nursing at the College of Mount St. Joseph in Cincinnati. "If they can’t incorporate it into their lifestyle, they don’t take it."

Wendt says agencies should approach medication management holistically — looking at all of the factors that bear on a patient’s decision whether to take pills as prescribed — as well as interventions that can help. The stakes are high, particularly for elderly patients who are taking multiple drugs.

Research shows that for every dollar spent treating a disease with medication, another dollar goes to treat morbidity and mortality linked to the misuse of medication, says Luann J. Capone, RN, MPA, vice president of quality management for Parkside Care Corp., a home health agency in Chardon, OH.

Many patients often must cope with up to 16 or 17 medications a day, often prescribed by a scattered group of physicians who don’t know about each other. Some use multiple pharmacies, so pharmacists may not be able to catch duplicate prescriptions or drug interaction risks.

As patients develop side effects to their drugs, more drugs are prescribed to cope with the side effects. "The problem is getting worse, because the medications are getting much more complex," Capone says. "As much testing as is done before a product goes on the market, there’s a lot of interactions and other things that aren’t tested."

In addition, there are patient compliance issues ranging from forgetfulness to patients simply refusing to take medications they don’t like. Keeping up with the complex web of drugs and their effects on the patient is a heavy load for a home health nurse already burdened by documentation and other requirements.

On the bright side, teaching patients how to handle their drugs intelligently can make the difference between the patient’s staying at home and requiring more intensive care.

Obstacles to proper medication use

What keeps patients from taking their medication properly? Although the classic excuse is forgetfulness, those who work with patients and study their behavior say the process is usually more complicated.

Wendt, who interviewed a number of elderly patients about their medication use, says she’s found two distinct phases when a patient begins taking a drug for the first time. During the first stage, which she calls a "testing" period, a patient will see how a drug fits in with his or her lifestyle. If it proves to be too much of an inconvenience or causes unpleasant side effects, a patient might abruptly stop taking it.

"They might say something like, This just doesn’t work in my body,’ and sometimes they would stop their medication after one dose," Wendt says. "Or the requirements for taking it might be too disruptive.

"For example, one pill . . . said you couldn’t eat or lie down for half an hour after you took it, and it had to be taken in the morning. That disrupted [the patients’] morning routine, so they just stopped taking it."

In other cases, side effects such as increased urination or impotence would lead a patient to stop. If patients continued to take the drug through this testing phase, their responses to new side effects or other problems were different. In those cases, patients usually would continue to take the drug while going to the physician to ask about the problem. Wendt says the patients she interviewed viewed compliance differently than health care professionals would. If a woman delayed a dose because she had plans for the afternoon, but did take the dose later, she would view that as being compliant. And patients were likely to listen to people who weren’t health professionals, who might advise them to try an herbal remedy or even stop their medication entirely.

"In one case, a woman who took about eight drugs one day stopped taking them all because she started believing they were making her sick, and her husband agreed with her," Wendt says. "So, on the advice of the husband, she stopped everything. When the doctor found out, the doctor said she had to take it, so she restarted it."

Many who work with elderly patients taking multiple drugs say that financial considerations are a factor in whether they’re able to take their medication as prescribed. "Cost is a big issue," says Patricia A. Nester, MSN, RN, assistant professor of nursing at Westchester (PA) University, who trains student nurses in performing home health medication assessments. "[Patients are] willing to say, I just can’t afford this.’"

Assessment first

All agree that a comprehensive, detailed medication assessment is the first and most important step in managing a patient’s medications. Nester and Michele L. Tucker, MS, RN, also an assistant professor of nursing at Westchester, are developing a medication assessment tool that elicits copious detail on a patient’s drug-taking habits.

"What we found sometimes is students would assume they had completed the assessment when they hadn’t even come close," Tucker says. "They would ask general questions such as, Are you having any problems taking your medications?’ That assumes that an elderly person would understand they were having a problem."

Even experienced nurses often don’t fill out forms as completely as they should, Capone says. "They’re not careful about getting the doses, they’re not careful about getting the stop dates, they’re not careful about documentation," she says, adding that careful documentation habits will lead to more careful medication monitoring.

This is also the time for nurses to learn as much as they can about other factors that can affect medication use — patients’ attitudes toward medicine, their learning ability, who gives them medical advice, and their financial situation. All those, Wendt says, play a part in determining how well a patient can stick to a drug regimen.

"People can know what they’re supposed to take, but they don’t do it because of these other factors — their activities, advice they get from people, cost, etc.," she says. "You need to sit down and work on incorporating [medication] into their lives, so you can get the compliance you’re looking for," she advises.

Assertive follow-up

Armed with information about the medication, the agency should follow up with physicians and pharmacists as needed. Capone says the goal isn’t just to prevent duplicate prescriptions or interactions, but to act as an advocate if the patient has too large a medication burden.

"I think nurses need to be more assertive with physicians and say, I can get [the patient] to take five medications appropriately; I think that’s realistic, but there’s no way we’re going to be able to get them to take these 12 medications,’" she says.

Nester notes that a patient who is having trouble with a medication might simply choose not to take it, unless he or she is encouraged to talk to the physician about alternatives. And as valuable and important as the initial assessment is, it is worth little if there are changes to the patient’s status that the agency doesn’t know about.

Those changes can come at virtually any time. As Wendt notes, patients may stop taking the drugs if they encounter problems. Other changes may be ordered by the physician or by other health professionals.

"What we found was if you don’t keep up, people might not think to tell you the new over-the-counter they’ve got," Tucker says. "They may not think to tell you they saw another physician, or they went to the ER, or they went to the urgent care center and now they’ve got something else. So we found a need for continuing review both of their inventory of meds and of their usage."

Capone says other surprises can come up simply because a patient forgets about a medication they were taking. She advises agencies to roll with the punches. "It is not unusual to think you have a very clear picture of the medications and the vitamins, and whatever else they have in the home; and you go back in a day or two and they say there’s something they forgot to tell you about," she says. "Expect that you’re going to be thrown a curveball," and as a professional, you have to go with the flow, she adds.

Obviously, the bulk of agencies’ medication management work lies in the area of patient education. Again, that education should take into account all the ways in which the patient’s life and medication affect each other:

• If a patient is illiterate or doesn’t understand English well, he or she should receive more simplified teaching materials or those written in their own language.

• If the number of pills is confusing, they should be taught strategies for keeping track of their medications — the use of pill boxes, charts, or cueing devices such as television shows or positioning nighttime drugs on a bedside table.

• If finances are a problem, agencies should provide information on financial assistance programs that target medication.

Teaching time

Capone suggests structuring the visits so that a set portion of time, perhaps at the end of the visit, is reserved for teaching. "If you sit down, maybe in the last 10 minutes of the visit, and say, OK, this is our teaching time,’ then the patient knows that this must be really important if this person, who is so busy, is setting aside time to teach me this medication," she says.

Wendt says that among some of the patients she interviewed, there were references to home health nurses "drilling" them — repeatedly asking them to describe what drugs they were taking and when they should take them. And although it sounds like a military technique, patients said it really helped them, she says.

Capone notes that careful documentation of the patient’s education prevents subjects from being missed. It’s particularly important in agencies where a patient doesn’t see the same nurse each visit. Under OASIS, she points out, some agencies hand a case off from an initial admissions nurse to other nurses for follow-up visits.

"There’s going to be room for inefficiencies, poor teaching, and missed opportunities for continuity in teaching if there’s not a structure in place," Capone says. "There needs to be a form that can be carried all the way through . . . so the [new] nurse knows where the other one left off, and the approach they’re taking."

At Parkside, the agency developed new documents that gave nurses more room to describe their teaching activities.

Encourage good habits

Capone and others say patients shouldn’t just be learning about their own drug schedule, but about good medication habits that can help them in the long run. Among those habits:

• Using only one pharmacy, so the pharmacist can catch interaction risks or duplicate prescriptions (often, if one doctor prescribes a brand name and another the generic form, the patient doesn’t realize it’s the same drug).

• Keeping a comprehensive list of all drugs taken and their dosages that can be taken to each medical appointment so physicians know the full range of a patient’s medication use. Capone’s agency creates a form on heavy card stock for patients; Tucker and Nester’s students used "medication passports" created by a drug company.

• Using up prescriptions such as antibiotics, and throwing away others when they are no longer needed.

• Telling health professionals about any herbal or over-the-counter medications they are taking.

• Going to a nurse or physician with side effects, rather than simply stopping the drug.

Wendt says many of the patients she talked to were grateful for the careful instruction they got from home health nurses. One woman she interviewed had developed an elaborate system for dealing with her 15 medications. She used multiple pill boxes, a notebook detailing her drugs that she kept with her medications in case she was taken to the hospital, and a binder of pharmacy information sheets on all her medications. "She had her drugs delivered, had been with the same pharmacy for 20 years, and often talked to them on the phone," she says. "She was just so coordinated in handling it.

"When she first came home from the hospital, she had home health nurses for three months, and . . . said she was very grateful for that. She said it took three months of them drilling her for her to learn about it," Wendt says. But the hard work paid off: "After that, when she was placed on new medications, she said it wasn’t that hard."

Luann J. Capone, Vice President of Quality Management, Parkside Care Corp., 831 South St., Chardon, OH 44024. Telephone: (440) 286-2273. Fax: (440) 286-7662. E-mail: caponel@dbconnect.net.

Patricia A. Nester, Assistant Professor, Westchester University, Department of Nursing, Room 112, S. Church St., Westchester, PA 19383. Office: (610) 436-3474. Home: (610) 269-9897. Fax: (610) 436-3083. E-mail: pnester@wcupa.edu.

Michele L. Tucker, Assistant Professor, Westchester University, Department of Nursing, Room 112, S. Church St., Westchester, PA 19383. Telephone: (610) 436-2693, Fax: (610) 436-3083. E-mail: mtucker@wcupa.edu.

Deborah Wendt, Associate Professor, Department of Nursing, College of Mount St. Joseph, 5701 Delhi Road, Cincinnati, OH 45233-1672. Telephone: (513) 244-4811. Fax: (531) 451-2547. E-mail: Deborah_Wendt@mail.msj. edu.