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Gretchen Alkema VA Greater Los Angeles Healthcare System Kathleen Wilber

Detecting & Improving Medication Use Among Vulnerable Elders: A Community-Based Medication Management Intervention. Gretchen Alkema VA Greater Los Angeles Healthcare System Kathleen Wilber USC Andrus Gerontology Center June Simmons, Sandy Atkins, Mira Trufasiu, & Dennee Frey

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Gretchen Alkema VA Greater Los Angeles Healthcare System Kathleen Wilber

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  1. Detecting & Improving Medication Use Among Vulnerable Elders:A Community-Based Medication Management Intervention Gretchen Alkema VA Greater Los Angeles Healthcare System Kathleen Wilber USC Andrus Gerontology Center June Simmons, Sandy Atkins, Mira Trufasiu, & Dennee Frey Partners in Care Foundation Gerontological Society of America Meeting November 19, 2007

  2. Collaborators USC Andrus Gerontology Center Kathleen Wilber, PhD Partners in Care Foundation Dennee Frey, PharmD June Simmons, CEO/LCSW Mira Trufasiu, MSG Sandy Atkins, MPA Susan Enguidanos, PhD Huntington Hospital Senior Care Network Eileen Koons, LCSW Lois Zagha, MFT Funding Support Administration on Aging Evidence-Based Prevention Initiative (#90AM2778) John A. Hartford Foundation Doctoral Fellows Program in Geriatric Social Work AARP Scholars Program VA Postdoctoral Fellowship (#TPP 65-007) Acknowledgements

  3. Problem of Medication Errors • 65+ = 12% of population but consume ⅓ of all drugs • 19 - 48% elders in community w/ med-related problems • 7,000 deaths annually by adverse drug events • Associated hospital costs = $2 billion • ¼ of adverse drug events are preventable

  4. Evidence-Based Practice (EBP)in a New Setting Implemented tested medication management protocols from: • Medicare home healthcare RCT to… • Medi-Cal waiver care management

  5. Home Healthcare Context • Site: Medicare-certified home healthcare • Population: 65+ w/ skilled nursing need & MD orders • Staff: Nurses w/ pharmacist support • Length of Stay: Up to 6 weeks • Contact: Up to daily visits

  6. Care Management Context • Site: Medi-Cal waiver care management • Population: 65+ dual eligibles w/ functional impairment • Staff: Nurses & social workers w/ pharmacist support • Length of stay: 1 month to 3+ years • Contact: Phoned monthly & quarterly home visit

  7. Care Management Sample (N=615) Site #1: n=216 Site #3: n=126 Site #2: n=273

  8. Targeted Medication Problems (Brown et al., 1998, Meredith et al., 2001) • Unnecessary therapeutic duplication • Psychotropic drug use w/ confusion or falls • Cardiovascular medication problems • Use of non-steroidal anti-inflammatory drugs (NSAIDs) with peptic ulcer risk

  9. Research Design

  10. Research Design

  11. Research Design

  12. Care Management Sample(N=615) • 81 years old • 80% female • 53% widows • 40% lived alone • 36% new to care management Photo by Rollin Riggs, NY Times

  13. Race/Ethnicity by Site (N=615)

  14. Language Preference(N=615)

  15. Health Status(N=615) • Mean # of meds = 8.76 (SD=4.3); 12+ meds = 22% • 38% ED, Hospital, or SNF in previous year • 22% falls in previous 3 months • 27% dizziness • 31% confusion

  16. Attrition • 10 left before med problems confirmed • ↑fallers (p<.05) • 100% w/ 1+ potential problem (p<.001) • 19 left before intervention completed • ↓ # of meds (p<.05) • Main reasons: LTC, died, or moved

  17. Prevalence Results (N=615)

  18. Associated Characteristics • Any problems ~ ↑ age, new enrollment, & ↑ meds • 2+ problems ~ ↑ meds • Therapeutic duplication ~ ↑ meds • Psychotropic ~ living w/ someone, new enrollment, ED/hospital/SNF, & ↑ meds • Cardiovascular ~ new enrollment

  19. Problems by # Meds

  20. Intervention Results(N=162)

  21. Staff Comments • “As a SW, I became aware of potential dangers or complications of some medications; I now look at all medications my clients are taking” • “No or slow response from the doctor…some clients have taken certain medications for so long that they were unwilling / fear to change” • “Uncomfortable addressing this issue with MDs ~ feel it is beyond my scope of practice”

  22. Conclusions • Med problems highly prevalent in Medi-Cal waiver sample • Intervention successful in care management • Critical need for meds management across continuum of care • Payment sources for meds management

  23. Next Steps • Disseminate Medication Management Improvement System ~ funded by Hartford Foundation • Computerized screening for potential problems • Integration into MSSPCare (by RTZ Associates) • Stand alone online version & algorithm for other software • Statewide replication in MSSPCare sites • National replication -- 2+ states • NCOA Readiness Tool • Seeking potential sites for 2008

  24. Photo by JL Forter

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