Categories: chronic care, home health, medication management, readmission rates, research, adverse drug events
In our current health care system, medication management for patients with chronic conditions is a notoriously complex task. The complexity becomes acutely apparent when we examine hospital admission and readmission rates.1,2 Alan Forster’s study of 400 patients discharged home found that 66% of adverse events were related to adverse drug events, while procedure-related complications were a far second at 17%. In the same study, Forster notes that patient education regarding their medications and post-discharge medication monitoring were two areas that required systematic improvement.3
What else do we know about the challenges of medication management? A review of 55 observational studies found that hospital-based physicians believe that information related to medications and reasons for changes to medications are two of the most important factors included in a discharge summary. However, the same study found that information related to medications is missing from the discharge summary up to 40% of the time.4 A study by David Budnitz examined emergency department visits for people over age 65 and found that in 2004 and 2005 there were over 177,000 emergency department visits due to adverse drug events.5 Finally, a small study by Eric Coleman found that patients with medication discrepancies (among pre-hospital, post-hospital, and an in-home assessment) had a 30-day hospitalization rate of 14.3% compared with 6.1% for patients without a medication discrepancy.6
There is some good news. Important advancements in care transitions management, including the Naylor and Coleman models, have shown promise in reducing readmission rates and adverse events.7,8 Unfortunately, these programs have their drawbacks as well, such as problems with staff recruitment and lack of comprehensive risk stratification methods.9 Perhaps an even greater barrier is the cost of implementing these programs, which require additional staff and resources.
With over 11 million visits each year, we maintain a wealth of clinical information at Amedisys. Internal analysis shows our average home health care patient is 82 years of age and on 12 medications. Unfortunately, it is hard to get a completely accurate picture of how many admissions are related to medication management because some hospital admissions related to medications are documented as falls, bleeding and other complications.
Information in hand, in 2011 we set out to examine the needs of our patient population and test a sustainable model for medication management. In collaboration with a team of scientists at the Purdue University College of Pharmacy, we developed a randomized controlled study that includes a representative sample of our home health care centers to rigorously evaluate a medication management intervention. For validity, it was important to us that the evaluation be conducted by external researchers.
HealthStat Rx, a specialty pharmacy, was chosen as the medication management partner for the evaluation and is providing telephonic services using pharmacists and pharmacy technicians. In broad terms, our medication management intervention is designed to promote better understanding of medication therapies, increase medication compliance, reduce the incidence of adverse drug events and lower readmission rates. Our intervention includes the following components.
- Assessment: A traditional home health start-of-care evaluation, including medication review, is performed by an Amedisys nurse or therapist.
- Medication Therapy Review: A telephonic comprehensive medication review by Healthstat Rx to identify and communicate any potential medication-related problems and review the appropriateness of medications prescribed.
- Personal Medication Record / Medication Action Plan: Healthstat Rx pharmacists develop a medication treatment plan to optimize patient adherence and drug therapy; document care and communication with primary care provider; and provide verbal and written education on all medications to the patient and Amedisys providers.
- Follow Up: Telephonic communication with the patient by Healthstat Rx and in-person communication from Amedisys clinicians in the home is used to monitor safety and effectiveness and review adherence to the medication regimen.
Three Amedisys home health care centers in North Carolina, West Virginia and Tennessee were randomly chosen to participate as beta sites and test the operational effects of the intervention. In the winter of 2011, the beta sites completed their testing. Though no conclusions can be drawn from the small sample of patients (n=69), the results were encouraging. Although more patients in the intervention group were on five or more medications, the number of hospitalizations for the intervention group was lower than our usual care control group. In addition, emergency department visits were 3% for the intervention group as compared to 19% in the control group.
Building on these results, we expanded the study with Purdue and HealthStat Rx in early 2012. Forty of our home health care centers were randomly selected to participate. In each care center, 28 patients will be randomly assigned to usual care or to the medication management intervention. Initial results are expected in early summer with dissemination of the findings to begin in fall of 2012 (subscribe by email or RSS feed to keep up with the findings).
We hope to see a successful medication management intervention that translates into less confusion and frustration for our patients and their caregivers, and fewer adverse drug events. Knowing that patients are especially vulnerable during the transition from an acute care hospitalization to home, we also expect our hospital partners to be interested in how the medication management intervention can improve hospital readmission rates for patients discharged to home health care. Reducing readmission rates would mean better patient care and satisfaction, lower costs for Medicare and other insurers, and a significant step toward an improved continuum of care.
About the Author
Julie L. Lewis is the vice president of health policy and government relations at Amedisys. She assists Amedisys in the continued development of a patient-centered, value-driven agenda for effective chronic disease management and end-of-life care that focuses on the quality and sustainability of the U.S. health care system.