By Melinda Young
Medication management services and coordination tops the list of essential interventions needed during transitions of care, according to the National Transition of Care Coalition (NTOCC).1
Care transitions can falter when patients’ medication assessment and management are not handled well, which is why case managers should follow some basic standards.
“Anytime you’re going from point A to B in the healthcare system, it’s a transition. That’s when things can go wrong,” says Tina Lipscomb, CCM, MSN, RN, RN case manager at Duke University Hospital in Durham, NC.
The first step is to reject the concept of discharging patients because that suggests an endpoint and that case managers are done with the patient, Lipscomb suggests. Instead, think of all patients as being transitioned to another place, even if that place is their own home.
Lipscomb has participated on a committee of NTOCC, looking at medication management. “We have a very passionate group; everyone on the committee is passionate about this topic of medication management,” she says. “We look at how to educate the public about their pharmacist. What does your pharmacist do for you? Where do you interact with your pharmacist?”
Best practices in medication management, listed in the NTOCC’s care transition bundle, include:
- assessing the patient’s medications list and needs;
- assessing social determinants of health that affect medication access;
- educating and counseling patients and caregivers about medications;
- developing and implementing a medication management plan.1
Here are some of the most important considerations in medication intake and management:
• Ask a pharmacist to check medication dosing. Case managers can help patients prepare for medication reconciliation by asking patients or their caregivers to bring a list of all medications and dosages taken by the patient at home. The list could be printed out or copied on the patient’s phone, Lipscomb suggests. If a tech-savvy caregiver or family member can put the list on the phone, it would be easy for the patient to pull up the information when asked about specific medications, dosages, and formulations.
“Some medicines are extended release, and some are not,” Lipscomb notes. “Know the formulation as well as the medication.”
The hospital pharmacist may conduct the first medication reconciliation, checking the patient’s list of medications against what the hospital record shows.
The goal is to catch omissions and mistakes. For instance, a patient may say he or she takes one medication for blood pressure, but the hospital’s electronic health record lists a different medication.
“A lot of patients have low health literacy and don’t understand,” Lipscomb says. “They come in and their blood sugar or blood pressure is completely out of control. We ask them if they take their blood pressure medication, and they say they take it every single day.”
However, a review of the chart may show that the medication had not been refilled for a couple of months. The case manager and pharmacist can collaborate to find out whether the patient had started a new medication that is not on the electronic record or whether they stopped taking the drug for reasons related to social determinants of health, such as cost or lack of transportation to a pharmacy.
Medication reconciliation is especially difficult when it is done at an inpatient rehabilitation facility where there may not be a pharmacist on site to assist, Lipscomb says. “Someone has to educate the patient, and this is a hard one,” she adds.
• Pharmacists can check medications against standard renal dosing. They look at potential medication side effects concerning the kidneys, Lipscomb says. “This should be done by pharmacists at every level of care,” she adds.
Case managers might need to help patients understand how some medications can harm their kidneys and other organs, even if they do not experience immediate discomfort or other side effects from using the drugs. For example, many drug classes cause renal insults, including painkillers, antibiotics, proton pump inhibitors, antidiabetics, antihyperlipidemics, and agents for erectile dysfunction. Some drugs can cause nephrotoxicity after one dose, but others need to be continuously monitored.2
Case managers and/or pharmacists can tell patients that even some over-the-counter pain treatments, such as nonsteroidal anti-inflammatory drugs, can result in renal function problems.2
• Review all medications, including over-the-counter medications (e.g., herbals, vitamins), allergies, and drug interactions, and reconcile with the patient’s health record. Pharmacists and physicians often ask patients about their non-prescription medications, but case managers can help patients understand which pills/drugs are included. Plus, case managers may be able to develop a rapport with patients, making it more likely that patients will share information about everything they take at home.
“They may not want to say, ‘I use this really weird supplement for my skin,’” Lipscomb explains. “We can help them understand how all these medications interact. Rapport is crucial because they have to feel comfortable talking to you.”
All healthcare providers are guilty of sometimes inadvertently shaming patients about their poor health habits, Lipscomb notes. “We’ve all seen this happen: ‘What are you doing? Why are you doing that?’” she says. “We can’t make patients feel bad for the choices they make at home. We have to listen to them and educate them.”
One example involves intracerebral hemorrhage among patients who have overused aspirin or BC Powder for pain. “BC Powder has a huge amount of aspirin in it, and a lot of people eat it for headaches like it’s candy. They’re increasing their bleeding risk and bleeding into their brains because of that,” Lipscomb explains. “Another is use of cocaine because it’s a vasodilator and makes the blood vessels very fragile, and they can burst.”
Case managers can ask patients which medicines they take, including all over-the-counter pills and formulations, as well as illicit drugs, such as cocaine and marijuana products. “We’re not judging them and not reporting it to the police,” Lipscomb says. “We need to make sure they’re safe.”
Patients may feel ashamed of using these products, so it should be handled carefully. “You can say, ‘When you go home, it increases your risk of [medical problems],’” she notes.
Obtaining a thorough and accurate list can depend on how well the case manager or pharmacist interacts with patients. “We have to make a patient feel comfortable. It’s about trust,” Lipscomb says. “Being a patient in the intensive care unit, you’re very vulnerable, and you need to feel safe. When you feel safe, you’re more willing to open up about things.”
• Identify problem medications and high-risk medications. The American Geriatrics Society (AGS) recently updated its AGS Beers Criteria about medication use in older adults. The 2023 AGS Beers Criteria provides information about potentially inappropriate medication use among people who are older than age 65 years in all settings, except hospice and end-of-life care settings.3
These criteria were developed by the late Mark Beers, MD, and colleagues in 1991. The purpose was to find medications for which potential harm outweighed potential benefit for older adults in nursing home settings.3
The STOPP/START criteria also can be used with older populations. STOPP stands for Screening Tool of Older Persons’ Prescriptions and START stands for Screening Tool to Alert to Right Treatment.4
• Identify and resolve polypharmacy issues. “Patients who are taking medication for anxiety or pain may be taking so many different medicines that they don’t realize they’re overdosing themselves,” Lipscomb says. “A prime example is a patient on medicine for pain and who can’t sleep. The person also takes Benadryl, a high dose, which can over-sedate them and cause a respiratory problem.”
The same thing can occur when patients take pain medication and drink alcohol. “Those are two depressing or sedating substances, which can have an adverse effect and make you go to sleep and not breathe,” she adds.
Patients who use illicit drugs could be taking something containing fentanyl, which can cause a person to stop breathing.
• Assess adherence and medication schedules. “We need to educate patients on when to take their medicines, like taking thyroid medication on an empty stomach,” Lipscomb says. “They should take that medication first thing in the morning, and we — both the case manager and pharmacist — can educate them on that.”
• Discuss the need for prescriptions written in the patient’s primary language. When possible, refer to pharmacies that provide labeling in different languages. “Ask a patient what language they are comfortable reading. That should be done on intake,” Lipscomb says. “A social determinant of health is to ask how comfortable the person is with filling out the medical forms and what language they prefer to read or write in.” For example, case managers can try to get to know the patient and see if they are more comfortable hearing medication instructions in Spanish, she suggests.
In addition to language differences, patients also might have hearing or visual impairment. Case managers might ask them if they can hear the oral instructions or if they need reading glasses to read written instructions.
“We need to know patient’s language and anything they might need as an aid to walk, see, [or] hear,” Lipscomb adds.
REFERENCES
- National Transition of Care Coalition. Care transition bundle seven essential intervention categories. Revised March 28, 2022. https://static1.squarespace.co...
- Alhassani RY, Bagadood RM, Balubaid RN, et al. Drug therapies affecting renal function: An overview. Cureus 2021;13:e19924.
- 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Ger Soc 2023;71:2052-2081.
- O’Mahony D. STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: Origin and progress. Expert Rev Clin Pharmacol 2020;13:15-22.
Medication management services and coordination tops the list of essential interventions needed during transitions of care, according to the National Transition of Care Coalition. Care transitions can falter when patients’ medication assessment and management are not handled well, which is why case managers should follow some basic standards.
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