by Denee Frey Haworth Press, Inc., 10 Alice Street, Binghamton, NY 73904-1580
Tele: 800-429-6784
Fax: 800-895-0582 E-mail: [email protected]
Web site:http://www.HaworthPress.com
Hardback: $44.95
Paperback: $22.95
As a home health and hospice nurse, I have often struggled with helping my patients manage their medications. As a nurse practitioner providing home palliative care visits, I find myself again looking for solutions to this problem.
"Improving Medication Management in Home Care: Issues and Solutions," edited by Denee Frey, PharmD, does not provide the quick and easy solutions I was hoping for, but is a compilation of studies and pilot projects. Home health agencies and programs for community-dwelling elders were the primary sites studied. The emphasis is on improving the safety of and decreasing adverse drug events in community-dwelling elders. The primary intervention involves introducing a pharmacist to the team. Many hospices already rely heavily on pharmacists for input and guidance.
The supporting background and stimulus for these studies and projects were similar. Statistics on the rapidly growing geriatric population, prevalence of multiple chronic conditions, and polypharmacy were cited in all. Add to this the physiological changes that occur during aging, multiple prescribing physicians, and little or no coordination of care, and elderly persons are at a high risk for adverse drug events.
Long-term care facilities have had regulations in place mandating pharmacy consultation. Home care has not had any such regulations, despite the fact that elderly patients at home can be just as frail and at risk. The implementation of Medicare Part D-of the Medicare Modernization Act of 2003-provides for medication therapies management services to high-risk beneficiaries. There is also the possibility of reimbursement for these services. One chapter is dedicated to a discussion of this benefit and how the service could be provided.
The first three studies cited implemented a medication management model in varying home healthcare settings. Each study developed criteria for inclusion, a process to screen patients, and a referral form. Polypharmacy, recent fall, and change in mental status were common criteria. The interventions pharmacists used were primarily chart and medication review with written recommendations. One study used a local school of pharmacy and had students make home visits. In another setting, a computer program was developed to screen Oasis data, which streamlined the process. Overall there were positive outcomes, a decrease in falls, and more appropriate medication use.
The most promising study involved a pharmacist providing home visits to every participant. In addition to reviewing medications and making recommendations, he provided teaching, instruction on blood pressure and glucose monitoring, education on home storage of medications, and support with applying for drug assistance programs. Unfortunately this service was too costly, and there was no reimbursement to continue the program after the study funding ended.
Continuity of care is a problem throughout our healthcare system. The transition from hospital to home provides many challenges and opportunity for error. Three NIH-funded studies examined this transition and employed advance practice nurses to provide oversight and teaching. The intervention resulted in a longer time before rehospitalization, fewer rehospitalizations, and better adherence to evidence-based practice guidelines in patients with heart failure. Other studies evaluated the discharge process and identified the weaknesses that can lead to medication errors. The addition of pharmacists to the hospital team was also evaluated with the many benefits and a decrease in adverse drug events.
Home medication management issues are not unique to the United States. The final chapter provides an overview of a conference hosted by the International Institute on Aging. The focus of this conference was medication management in older patients. Every aspect of care was presented-from prescribing practices to hospital discharge to home management. Participants represented all disciplines, physicians, nurses, and pharmacists. Possible strategies to improve all areas were discussed, and similar research studies are being performed in other countries. Collaboration and sharing of information within the international community represents another avenue to exploring these problems and finding possible solutions.
Although it did not provide immediate, quick-fix solutions to medication management in the home setting, this book does provide a useful overview of the early research efforts into the problem. The models of care described hopefully will spark further research. The Medicare Modernization Act may offer a source of funding to provide a service that is desperately needed. The book describes the many elements that contribute to poor management. Improved prescribing practice and attention to drug-drug interactions is a good first step. Increased use of pharmacists throughout the process can only lead to better outcomes.
The book is not long: 155 pages. The background information for the studies and projects can be redundant and tedious to read. It does provide a good overview of the issues related to medication management in home care with a focus on the elderly population. This is a problem that will only continue to grow. I recommend this book to anyone who is interested in this topic. It also is valuable to anyone planning quality improvement projects in their own organization related to medication management.
Nanci Tansey, APRN, GNP
is a Director of the Out-Patient Palliative Care Program, Mercy Hospice and Palliative Care.