Tuesday, 24 May 2016 13:53

Value Quality of Care Coordination – Medication Managment

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john derrThis is the sixth article in a series addressing the value proposition of long-term, post-acute care (LTPAC) providers and LTPAC health IT vendors. The articles focus on five major valued quality of care coordination (VQCC) differentials between LTPAC providers and acute/ambulatory care providers. This series of articles is based on the LTPAC health IT collaborative ONC brief written in May 2015 for Karen B. DeSalvo, national coordinator for health information technology and acting assistant secretary for health with the U.S. Department of Health and Human Services (HHS), titled Health Information Technology Use & Value Delivered by The Long-Term and Post-Acute Care (LTPAC) Sector.

Readers can find the complete ONC brief on the LTPAC HIT Collaborative website (http://www.ltpachealthit.org/sites/default/files/ONC%20Brief%20LTPAC%20HIT%20Value%20and%20Use_May%201%202015.pdf).

The first three VQCC value proposition differentials were duration; eAssessments; and chronic care. The fourth VQCC is medication management. The VQCC LTPAC medication management differential:

  • Provides for a comprehensive review of each patient’s medication management and reconciliation by a licensed consultant pharmacist as it relates to all factors that affect the clinical outcomes of medications, including laboratory, diet, and therapy. Clinical information reconciliation (CIR) addresses medication reconciliation, medication indication for use, allergies, allergy intolerance, and reactions.
  • Provides for a review of the hospital transition-of-care reconciled medication results as it pertains to medications taken before hospitalization, potential drug interactions, and polypharmacy. It ensures that each medication has an indication.
  • Ensures that skilled nursing facilities (SNFs) have a medication team comprised of the nurse, medical director, primary care provider, institutional pharmacy, and consultant pharmacist to conduct comprehensive, integrated, person-centric management of medications. This also involves the electronic health record (EHR), electronic medication administration record, and in some nursing homes,an automated medication dispensing instrument.  
  • Provides for medication counseling when a patient transitions to another provider or home.

Medication management is very important to every patient, but it’s more important when a patient is being transitioned from an acute-care setting to a SNF or home healthcare agency (HHA) and then to their home. This is especially critical when the patient requires chronic care and has comorbidities. The second VCQQ, chronic care, notes how important LTPAC diagnosis, care provision, and maintenance are to patients requiring chronic care, and how these persons make up a large percentage of Medicare costs. One of the important aims in chronic care is to establish each patient’s medications and then provide medication management in order to meet the indicators established by the prescribing physician and to prevent polypharmacy. As pointed out in the previous VQCC bullet points, the ideal provider location to establish a patient’s medication regimen is an SNF.

In 2016, Rand Corporation performed a literature review of medication reconciliation and summarized that:

  • Medication reconciliation (MR) is a national patient safety goal.
  • Approximately half of hospital-related medication errors and 20 percent of adverse drug events (ADEs) occur during transitions, admission, transfer, or discharge from a hospital.
  • Seventy-five percent of medication errors are preventable.
  • The economic impact of medication errors is substantial.
  • MR is the most common type of health system error.
  • Preventable ADEs are associated with one in five injuries or deaths from errors.
  • Drug-related morbidity and mortality estimates were approximately $177 billion in 2000.

What is medication management? There are many different definitions describing the processes and regulations. To list only a few, there is medication therapy management (MTM), medication management (MM), medication reconciliation (MR), and drug regimen review (DRR). It is my belief that this involves not just one clinical element, process, or form, but a management of a person’s medications throughout their life and across their spectrum of care (if they are under professional care). In my research I found a very comprehensive definition in the 2012 Patient-Centered Primary Care Collaborative (PCPCC) Resource Guide on “The Patient-Centered Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes” (https://www.pcpcc.org/sites/default/files/media/medmanagement.pdf):

“Comprehensive medication management is defined as the standard of care that ensures each patient’s medications (whether they are prescription, nonprescription, alternative, traditional, vitamins, or nutritional supplements) are individually assessed to determine that each medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended. Comprehensive medication management includes an individualized care plan that achieves the intended goals of therapy with appropriate follow-up to determine actual patient outcomes. This all occurs because the patient understands, agrees with, and actively participates in the treatment regimen, thus optimizing each patient’s medication experience and clinical outcomes.”

I realize that this definition is referring to a person in their home, but in transitions of care from an episodic incident, over 40 percent of the time the person is transitioned to a SNF, which becomes their home for a short period of time for rehabilitation. The SNF has the time, professional staff, and capability to develop and include medication management in a person-centric, electronic longitudinal plan before the person is transitioned to their home of choice or to a HHA.

Medication source is a barrier to true medication management. There is a big push on medication reconciliation (MR) lists, especially when it comes to rehospitalization. But a list is just a list, and whoever is filling out the MR list should ensure that it is accurate.

In today’s world medications can be acquired from various sources, including the retail pharmacist, hospital clinical pharmacist, senior pharmacist, and consultant pharmacist. The medications can be obtained from various pharmacies as prescriptions or over-the-counter medications. The trend of relabeling prescription medications to over-the-counter continues, and these medications can cause adverse drug reactions. MR requires the collection of data from various sources, not just what the hospital provided before the transition of care.

An SNF represents a tightly controlled, closed environment that uses an institution pharmacy to provide medications. Today’s leading LTPAC clinical technology vendors have incorporated an electronic medication administration record (eMAR) to assist nurses in their medication administration. An eMAR, as defined by CMS, automatically tracks medications from order to administration using assistive technologies.

The MR also incorporates the act of reconciling any discrepancies between lists. The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 also requires a standardized MR. In the SNF, the process is assisted by a licensed consultant pharmacist supported by the American Society of Consultant Pharmacists (ASCP). Many of these consultant pharmacists are also certified by the Commission for Certification in Geriatric Pharmacy (CCGP) and are very valuable in chronic care and polypharmacy.

Gaps in True Medication Management

True, comprehensive medication management has to be a closed, continuous process throughout the spectrum of care, especially for persons requiring chronic care. The major gap is in the transition of care, when a comprehensive MR has to be conducted and transmitted electronically to the next care setting. The following is an example graphic of a transition of a person from their episodic incident to their home. At each transition of care (ToC) point, there is a possible discrepancy in the MR.

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There are also gaps within the SNF medication management process that would improve what already is the best provider site to establish medication within a comprehensive EMR. First, within the SNF’s EMR, there has to be an integrated system incorporating all clinical technology that affects the patient’s medication management, as well as an integration of the consultant pharmacist software application, which provides medication review.

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Another gap is in the administration of the medications. Today, in the majority of SNFs, there is a medication cart that is filled with the medication punch cards from the institutional pharmacy with a 30-day supply of a patient’s medications. This manual process causes problems when medications are changed or when the patient is transitioned from the facility. Unused medications that are already paid for are a cost problem for SNFs.

This long has been a manual process, but it can be automated. As an example, below are two graphics; the first demonstrates the traditional distribution on medications and the second depicts the use of a medication-dispensing instrument.

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There are a number of companies that provide instrumentation for medication runs within SNFs. One of these is the Talyst’s InSite System. This in-facility medication dispenser is designed for improving the medication supply chain into SNFs, and medication management within SNFs, thereby aligning them more closely with acute-care medication management practices. The InSite System is being expanded to make it the authoritative SNF informatics hub, wherein real-time data aggregation, data visualization, and even simulations occur among data a) from medication therapy and regimen management; b) from medication prescribing practices and other physicians’ orders; and c) from medication administration outcomes noted in nurses’ clinical notes, and from in-facility EHRs and eMAR. Having an in-facility medication dispenser will eliminate a gap in the process and also eliminate medication waste.

Another gap in true medication management involves polypharmacy. Polypharmacy is defined by one medical dictionary as “the practice of administering many different medicines, especially concurrently, for the treatment of the same disease (and) the concurrent use of multiple medications by a patient to treat usually coexisting conditions and which may result in adverse drug interactions.”

This can happen with various sources of medications, especially when a person is going through transitions between provider sites.

The emerging field of pharmacogenomics offers a very valuable tool in eliminating polypharmacy issues. It will help eliminate unnecessary medications and ensure that medication is correct for each individual patient as we move into personalized medicine. The National Institutes of Health (NIH) U.S. National Library of Medicine defines the field like so:

“Pharmacogenomics is the study of how genes affect a person’s response to drugs. This relatively new field combines pharmacology (the science of drugs) and genomics (the study of genes and their functions) to develop effective, safe medications and doses that will be tailored to a person’s genetic makeup.

Many drugs that are currently available are ‘one size fits all,’ but they don't work the same way for everyone. It can be difficult to predict who will benefit from a medication, who will not respond at all, and who will experience negative side effects (called adverse drug reactions). Adverse drug reactions are a significant cause of hospitalizations and deaths in the United States. With the knowledge gained from the Human Genome Project, researchers are learning how inherited differences in genes affect the body’s response to medications. These genetic differences will be used to predict whether a medication will be effective for a particular person and to help prevent adverse drug reactions.” (https://ghr.nlm.nih.gov/primer/genomicresearch/pharmacogenomics)

The medical, pharmacist, and LTPAC communities are just starting to realize the value of pharmacogenomics solving polypharmacy issues and improving quality of life for geriatric persons requiring chronic care. One of the major obstacles is the cost of the laboratory tests. In order to establish some quantifiable documentation on the cost savings, there was a study with the following conclusion:

“A recent study by the University of Utah on the comprehensive approach to medication management, based on the YouScript CDS system, demonstrated a 39-percent reduction in hospitalizations and a 71-percent reduction in emergency department visits among a cohort of elderly, polypharmacy-treated patients subjected to CYP genetic testing and comprehensive interaction management in the four months following testing. In total, more than 95 percent of prescribing physicians found the CDS-generated reports helpful and approximately a half implemented recommended changes in patient medication regimens.” (Brixner D, Biltaji E, Bress A et al. The effect of pharmacogenetic profiling with clinical decision support tool on healthcare resource utilization and estimated costs in the elderly exposed to polupharmacy. J. Med. Econ. 19, 1–40 (2015). http://www.futuremedicine.com/doi/abs/10.2217/pme.15.47)

Summary

The VQCC differential of medication management is very important in providing personally tailored healthcare and utilizing the advantages of an SNF. When the gaps noted above are closed, the SNF will be one of the best medication management sites in the spectrum of care because of the other VQCCs noted, especially the duration of stay and the professional environment.

About the Author

John F. Derr, RPh is CEO of JD & Associates Enterprises, specializing in strategic clinical technology with a focus on person-centric electronic longitudinal medication management and LTPAC. He has more than 50 years of top executive-level experience with Squibb, Siemens, Tenet (NME), Kyocera, MediSpan, and EVP of AHCA. He was SVP, CIO, and CTO for Golden Living, LLC. He is a member of corporate boards providing guidance on clinical healthcare IT and medication management. He represents LTPAC and pharmacy as a member of the U.S. Department of Health and Human Services (HHS) HITECH Committee on Standards. Derr is a graduate of the Purdue School of Pharmacy and a 2006 Distinguished Purdue Alumnus.

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Last modified on Wednesday, 13 July 2016 06:09

John F. Derr, RPh is CEO of JD & Associates Enterprises specializing in Strategic Clinical Technology with a focus on person centric electronic longitudinal medication management and LTPAC. He has over fifty years of top executive level experience Squibb, Siemens, Tenet (NME), Kyocera, MediSpan and EVP of AHCA. He was SVP, CIO and CTO for Golden Living, LLC. He is a member of Corporate Boards providing guidance on clinical Health IT and medication management. He represents LTPAC and Pharmacy as a member of HHS HITECH Committee on Standards. Derr is a graduate of Purdue School of Pharmacy and a 2006 Distinguished Purdue Alumnus.