Looking for a Cheap and EasyEvidence-Based Program?Partners in Care FoundationJune Simmons, CEOSandy Atkins, VP, Institute for Change

Presented By:Sandy Atkins, VP Institute for ChangePartners in Care Foundation

Amy Adams, Manager Support Services B.S.Area Agency on Aging of Tarrant County (AAA)

Jennifer Severance, PhDSenior Citizen Services (SCS)

Samantha Powell, M.S., R.D.N., L.D.Meals On Wheels, Inc. of Tarrant County (MOWI)

2ObjectivesUnderstand HomeMeds

Recognize the benefits of the HomeMeds program

Learn strategies for implementing HomeMeds involving multiple partners

Agenda

Introducing Home MedsMedication ProblemsBenefitsThe ProcessCostsImplementationPartner AgenciesSoftware DemoQ&A

Partners in Care FoundationWho We ArePartners in Care serves as a catalyst for shaping a new vision of healthcare by partnering with organizations, families and community leaders in the work of changing healthcare systems, changing communities and changing livesfocusing on home and community careWe evolved from the VNA of Los Angeles to be a nimble force for change.

5The Problem Medication Errors are:

Serious: Over 700,000 people go to ED each year for adverse drug events

Costly: Drug-related morbidity/mortality $170 billion -ER, hospital/readmissions, SNF etc.

Common: Up to 48% of community-dwelling elders have medication-related problems

Preventable: At least 25% of all harmful adverse drug events are preventable

The Solution: HomeMedsHomeMeds is designed to enable community agencies to keep people at home & out of hospital by addressing medication safetyPractice change with workforces/settings that already go to the home more cost effective use of existing effortFocus on potential adverse effects (falls, vitals, confusion) then determine if medications may be part of the cause

7Developed first for home health through funding from the John A. Hartford Foundation as a sequel to their initial investment in SNF medications issues and the creation of the Beers criteria subsequent funding came from the Administration on Aging which supported adapting the HomeMeds model to a more typical community setting focused on high-risk Medicaid and Dual patients at home through Medicaid Waiver programs focused on prevention of nursing home placements. In these programs the staff already go to the home, do a full assessment and even gather the full medications inventory. So the costs of identifying meds are already in the system. More of a social model, these medications data are often not driven to full value. Embedding this powerful HomeMeds tool facilitates such programs to identify and flag alerts for medications (combined with observations of signs and symptoms such as dizziness, confusion and history of recent falls.) The addition of the pharmacist to the team is a crucial component. HomeMeds is designed to enable community agencies to keep people at home and out of the hospital by enhancing these programs ability to address medication safety and take the identified and confirmed problems forward medical corrective action.Moving from nursing home diversion waivers, a number of promising new sites to further distribute this powerful HomeMeds resource have been identified. The obvious one is embedding it in the rapidly spreading Transitions programs for Fee For Service Medicare patients and others at risk. Many other programs within the AoA Aging Services Network are also promising targets wherever we already pay for someone to go to the home and gather assessment data on seniors and persons with disabilities we should gather and review the full array of medications and supplements in the home and take key findings to pharmacist review and quick alert to the physician. This can include senior center care management programs, other state-sponsored in-home care management programs, potentially home-delivered meals programs, in-home supportive services programs. Wherever we have eyes and ears in the home, we can gather medication data that medical care providers need in order to optimize care. It is not necessary to be a medical expert to gather the medications information a very broad spectrum of individuals that can read, observe and interview can do this the HomeMeds software captures the issues of concern, the pharmacist screens out false positives and then healthcare providers can learn of and correct these harmful problems. It provides a very new platform for an excellent and fruitful partnership between community care and medicine.

7HomeMeds: Bridge from Home to HealthcareAny symptom in an elderly patient should be considered a drug side effect until proved otherwise. (Gurwitz et al. 1995)

Expected ResultsHomeMeds: Saves Money, Saves LivesFalls and other adverse effects improved through collaboration between pharmacists and members of the care team46.7% of older adults screened in 14 sites from 2007 to 2010 had risk for medication-related injuryEstimated Savings from 7,000 Screenings: up to $1.5 million.

HRSA, 2010, www.hrsa.gov/patientsafety

10From our funded demonstrations and subsequent Hartford-sponsored spread of this work, evidence of major savings from this very cost-effective intervention are clear. Savings from early 7,000 screenings are estimated at $1.5 million by preventing falls and other adverse effects. New applications will bring new savings by reaching millions instead of a few thousand, the savings effects will multiply. And the new applications will have even more powerful cost benefit. Embedding HomeMeds within Transitions programs clearly targets the intervention to an even higher risk population where the avoidable medical costs are obvious and thus the savings even more easily demonstrated.Costs for spreading HomeMeds are in the capacity building rather than the intervention. Equipping workforces that already go to the home and assess patient, environment and medications with this tool results in current investments in care and support having much greater yield better outcomes and much lower healthcare costs. This is certainly true in Medicaid waivers and AoA care management programs. We have found in many home care management programs that 46.7% of the older adults screened in with risk for medication-related injury (an average of 2 to 3 potential problems per client) Average of 2.5 potential problems per client. These kinds of community programs target an earlier point in the health trajectory than hospitalization, allowing significant prevention. Targeting immediate post-acute high-risk patients through Transitions interventions - building HomeMeds into these programs - has obvious clinical and cost-benefit impact.

10HomeMeds Evidence-Based RecognitionAoA recognition as an evidence-based prevention program Highest Level of EvidenceNational Registry of Evidence-based Programs and Practices (http://nrepp.samhsa.gov) (soon to be published)Quality of research: 3.2/4Readiness for dissemination: 4/4US Agency for Healthcare Research and Quality (AHRQ) Innovation Exchange Strong evidence ratinghttp://www.innovations.ahrq.gov/content.aspx?id=2841

11Risk-Screening ProtocolsIdentified by national expert consensus panel Targets problems that can be identified and resolved in the home:Positive response by prescribersMinimize alert overload: based on signs/symptoms.Unnecessary therapeutic duplication

Use of psychotropic drugs in patients with a reported recent fall and/or confusion

Use of non-steroidal anti-inflammatory drugs (NSAID) in patients at risk of peptic ulcer/gastrointestinal bleeding

Cardiovascular medication problems -High BP, low pulse, orthostasis and low systolic BP

Limited to only these medication-related problemsA model for improving medication use in home health care patients . Brown, N. J., Griffin, M. R., Ray, W. A., Meredith, S., Beers, M. H., Marren, J., Robles, M., Stergachis, A., Wood, A. J., & Avorn, J. (1998). Journal of the American Pharmaceutical Association, 38 (6), 696-702.1212(1) "A model for improving medication use in home health care patients " Brown, N. J., Griffin, M. R., Ray, W. A., Meredith, S., Beers, M. H., Marren, J., Robles, M., Stergachis, A., Wood, A. J., & Avorn, J. (1998). Journal of the American Pharmaceutical Association, 38 (6), 696-702.

HomeMeds Intervention ProcessRoles of the pharmacistScreen alerts to confirm problemsCommunicate with prescribersConsult with care manager Identify problems beyond protocolsAssist with complex casesEducate staff about medications/risks

14Avg. 30 minutes per clientScreen alerts to confirm problems in light of dose/frequency, diagnoses, symptoms, other medications, etc. Communicate with prescribersConsult with care manager to develop care planIdentify medication-related problems beyond protocols. Assist with complex cases educate patient/familyEducate staff about medications/risksWhat does it cost?Planning, setup, consultation, support:$3,000, one-time fee

Software licenseFrom $200/month for up to 50 new clients created/mo.Negotiate shared licenses for smaller sites

Training$5,000 on-site plus travel (shared multisite OK)$250 per refresher webinar (after year 1)

15Covering the CostSoftware, Startup & PharmacistOlder Americans Act Title III-D

Pharmacist coverage alternativesPharmacy School students & supervisionWaiver purchase-of-service dollarsVolunteer community pharmacistMedicare MTW: Medication Therapy Management (through local pharmacy or patients Part D plan)

16Whos Implementing HomeMeds?Medicaid 1915(c) Waiver programs for Dual EligiblesCare Transition programsCBO under contract with medical groupsArea Agencies on Aging & Senior CentersMeals on WheelsHome Health/Homecare AgenciesAssisted Living & Affordable HousingNative American Tribal Community

HomeMeds at AAA

Amy AdamsManager, Support ServicesArea Agency on Aging of Tarrant County

HomeMeds: Innovative adaptations & sustainability

Why should non-healthcare agencies work on medication safety?Medications are a huge factor in readmissions and fall related injuriesA view into ones home provides unique perspective otherwise unavailable to healthcare providers Home medication reconciliation is a national patient-safety goal

20High risk includes patients with diabetes, CHF, pnemoniaTo thrive, need to play a role connecting the home with the healthcare system, why are medications a huge factor in readmissions?20Medications & Care Transitions72% of post-discharge adverse events are related to medications-and close to 20% of discharged patients suffer an adverse event *

Medication reconciliation and risk assessment is a core element of every care transition intervention

Why wait for a hospitalization? Why not intervene earlier?*from Mary Andrawis, PharmD, CMMI, presentation to Drug Safety Panel, May 10, 2011(cite Forster et al. Annals of Internal Medicine. 2003; 128: 161-167. / CMAJ FEB 3, 2004; 170 (3)

Seniors and others with complex conditions are most at-risk when transitioning from hospital to home or other care setting.1 in 5 patients discharged from the hospital suffer an adverse event a startlingly high 72% of these adverse events are related to medications.It is now well documented that medications account for nearly 2/3s of inappropriate readmissions to hospitals within the first 30 days after discharge a major patient safety issue with very high personal and cost impact.Partners in Care is moving actively into Transitions work, providing a proven model into which we have infused HomeMeds a natural marriage of new approaches in the effort to promote better health and thus reduce avoidable use of healthcare resource, especially readmissions.

21Partners in CareAAA/UWSCSMOWICongregate programSafe Communities/ Fall PreventionA Matter of BalanceFt. Worth Fire DepartmentMedstar-Emergency Responder

Homebound clientsHospital referralsMedstar-Emergency Responder

How did AAATC become involved in this program? Ask the question. Why-Safe Communities initative, what draws your interest to this program?22Home visits uncover many secrets of which physicians may not be aware OTCs Over-the-counter medications Prescriptions from other other providersAdverse effects such as falls, dizziness, confusionAdherence issuesOut of system meds: Drugs from other countries, borrowed, Wal-Mart $423Over-the-counter medications & supplements Medications prescribed by other providersAdverse effects such as falls, dizziness, confusionAssessment information Alcohol use, depression screen, vital signs, etc.Incorrect self-dosing (3x/day vs. 3 pills w/lunch)Adherence issues economic, side effects, etc.Un-manageable care $4 co-pays at Wal-Mart < Part D co-pay $ Meds from other countriesMeds borrowed from friends and family

23Consumer Feedback Mr. Johnson went from 20 meds to just 8:You have saved us money on monthly refills and my life! We cannot thank you enough!

AAA in Tarrant County, TXCaregivers have positive response.Beneficial to gain better understanding of their loved ones medications and provides confidence when accompanying them to doctors visits

Don Smith, Director, Tarrant County AAA: HomeMeds is the easiest of all evidence-based programs to implement. We can see results - decrease in number of medications, decrease in falls pre & post.

25HomeMeds at Senior Citizen Services

Jennifer Severance, PhD

HomeMeds in Congregate SettingsSenior Citizen ServicesLocations:Senior centersFaith-based organizationsSenior housing

Licensed Clinical Social WorkerSenior center directorsSocial work interns

2764% with low to medium medication adherence57% with at least 1 alert43% with unnecessary therapeutic duplication35% with increased risk of falls or dizzinessHomeMeds in Congregate SettingsLessons learnedIndividual factorsSide effects, cost savings, supplement usePerson-centered resolutionsNon-medical options

Implementation factorsPrivacy issuesCommon refusalsEnhancing social services and partnerships

Add-on to other recognized Evidence Based Programs:

30HomeMeds in Congregate SettingsHomeMeds integrates really well with CDSMP and MOB. Each has a module on medication management and HomeMeds reinforces this and integrates and is easy to refer people to.

We're definitely getting our money's worth if you relate this to prevented hospitalization. We spend $50/person on HomeMeds.

30HomeMeds at MOWI

Samantha Powell M.S., R.D.N., L.D.Registered/Licensed Dietitian

MOWI HomeMedsMeals on Wheels of Tarrant County, Inc.Homebound clientsCertified Pharmacy Tech (CPhT)Track fall history for clients with alerts

32What we are seeing at MOWI.Several doctorsSeveral pharmaciesMiscommunication between doc and clientNutritional supplementsOTC drugs

It is estimated that 1 in every 4 hospital admissions of elderly patients is caused because of medication problems including drug interactions.Over a period of time when a patient goes to the hospital they are seen by many different doctors who do not know their health history or medication history.The doctors prescribe medications and most of the time dont know what the patient is taking which can cause drug interactions or duplicate therapy.And most elderly are not even sure what they are taking or why, they were just told to do so by the doctor and they want to feel better. 33MOWI HomeMedsOctober 2012-April 20131038 Clients 554 Clients with alerts (53%)1133 Total number of alerts 247 Alerted clients with a fall history 342 Number of dizziness/fall alerts

Client Story: 34Alerts and Fall History1038 clientsFall History35Dizziness/ Fall alerts(1132 Total Alerts)

Costly Mistakes

Hip & Thigh Bone (JPS) $53,247 (7 days)

Shoulder, Wrist, Hand (JPS)$31,148 (2 days)

Total Cost = $70,434

HomeMeds Cost: $50Rehabilitation: (HealthSouth)$17,187 (10 days)Common InteractionsClients with hypertension takingLopressor (metoprolol)as well asCalan (verapamil)

Are at increased risk for:Congestive Heart FailureSevere high blood pressureRapid heartbeatFaintingSevere Chest Pain

A common medication given for hypertension is Lopressor (metoprolol). When Lopressor is given with either Verelan/Calan/Isoptin (verapamil) or Cardizem (diltiazem) (CALCIUM CHANNEL BLOCKERS FOR HIGH BLOOD PRESSURE) there could be serious consequences. Some adverse reactions that could happen is congestive heart failure, severe high blood pressure, or severe angina. It can also increase the chance of the patient having a rapid heartbeat or even fainting.This is also a sign of duplicate therapy which we have already seen a lot of so far in our reports.38Costly MistakesChest Pain

Total Cost = $17, 070

HomeMeds Cost: $50Bringing it Home With Stories of Success

Mrs. P56 years young3 grocery bags full of med bottles26 different medications found10 alerts generatedDoc only prescribed 11

Conclusion HomeMeds is a proven tool for improved medication safety, health and well-being for older adults.

It is an affordable, evidence-based program that is a perfect bridge for partnerships between community agencies and healthcare.

HomeMeds: Call us or email us!Email us at HomeMeds@picf.org HomeMeds Website: www.HomeMeds.org HomeMeds Information Packet:http://www.homemeds.org/landing_pages/14,3.html Partners in Care Website: www.picf.org Sandy Atkins, VP: satkins@picf.orgPhone: 818.837.3775

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