Megan R. Undeberg, PharmD, RPh

University of Minnesota College of Pharmacy-Duluth

Department of Pharmacy Practice and Pharmaceutical Sciences

and

Community Memorial Hospital Pharmacy, Cloquet, MN

June 26, 2012

Learning Objectives Following completion of this portion of the CE you will

Define role of federal Title III-D funding.

Explain development of MTM services for older Americans under Title III-D funding.

Understand benefits of partnering with local government and civic agencies to advance chronic disease state management

Develop new models of MTM delivery in rural and/or underserved populations.

Question 1 Title III-D funding provides for A. Seed grant funding to develop new services for

underserved older Americans. B. Development of programs to increase quality of life for

Americans over the age of 60. C. Partnerships with area agencies to expand programs

such as fall prevention and medication safety. D. All of the above.

Question 2 Examples of Disease Prevention and Health Promotion

(DPHP) Title III-D Older American Act Programs do NOT include:

A. Chronic disease state management programs.

B. Assistance with yard work and home maintenance.

C. Fall prevention programs and safety profiles.

D. Programs supporting nutrition improvement.

Question 3 Rural residents are at increased risk for poor health outcomes due

to the following factors EXCEPT: A. Lower income and socioeconomic class disparities. B. Decreased access to health care services, including

pharmacies, clinics, and hospitals. C. Increased availability of third party insurance coverage, both

health care and prescription benefits. D. Less availability of family medicine physician primary health

care providers.

Question 4 Benefits of MTM in a rural setting does NOT include: A. Increased use of emergency room services to manage

chronic disease states. B. Increased communication between physicians, mid-

level providers, pharmacists, patients, and family members.

C. Improved comprehensive disease state management. D. Decreased medication use.

Question 5 Key concepts to providing new pharmacist-based services in

a rural setting include: A. Partnering with community agencies, including

churches, community centers, and local businesses. B. Forming relationships with area healthcare providers

and systems. C. Obtaining credentialing with local insurance providers. D. All of the above.

What Is Rural? Population of U.S. in rural areas:

20%

Physicians serving rural areas: 10%

Population >65 years: Rural: 18%

Urban: 15%

Population below poverty level: Rural: 14%

Urban: 11%

www.ruralhealthweb.org “A National Rural Health

Snapshot”.

http://www.srph.tamhsc.edu/centers/rhp2010/litrev.htm “Rural Healthy People 2010”

http://www.fhwa.dot.gov/planning/census_issues/metropolitan_planning/cps2k.cfm “Census 2000 Population Statistics”

The “KEY” Question How do we fund new

programs within our healthcare systems in the rural sector?

Do partners exist?

Historical Perspective 1965: Older Americans Act signed by President

Lyndon B. Johnson

Objectives:

Help older persons secure and maintain maximum independence and dignity in a home environment

Remove barriers to independence for older persons

Provide a continuum of care for the vulnerable elderly

Common Services for Older Adults Senior Centers

Meals on Wheels

“Care in Containers”

Support Services, including adult day care

National Family Caregiver Support Programs

Health and Wellness Programs

“Matter of Balance”

Chronic disease self management

Older American Act Title III-B SUPPORTIVE SERVICES

Assisted transportation

Chore help

Counseling

Legal aid

Legal education

Information and assistance

Older American Act Title III-D Disease Prevention/Health Promotion

Medication Management

Medication Screening

Mental Health Screening

Mental Health Referral

Title III-D Funding Focus: Initiation of programs to assist older adults (ie, >60

years old)

Prevent chronic disease development

Management of existing chronic disease states

Increase healthier lifestyles

Develop and enrich relationships with Area Agencies on Aging

Provide seed grant funding to stimulate new programs targeting disease prevention and health promotion

Target Populations

60 years of age and . . . Low income and:

Greatest economic need

Greatest social need

Minority status

Frail, disabled, or functionally impaired

Rural or isolated

Limited or non-English speaking

Hearing impaired or visually impaired

At-risk for institutional placement

Finding the Foundation Area Agencies on Aging

Arrowhead Regional Development Commission’s (ARDC) Arrowhead Area Agency on Aging

Seven “arrowhead” Counties Aitkin

Carlton

Cook

Itasca

Koochiching

Lake

St. Louis

Goals: Partner with public and

private organizations to develop and coordinate community care

Age successfully in place

Senior Care Facts From: American Society of Consultant Pharmacists

Today : 40 million adults aged 65 and older

By 2030: 72 million

Every day in the United States, another 10,000 people reach the age of 65

Some type of disability (e.g. difficulty in hearing, vision, cognition, ambulation, self-care, or independent living) was reported by 15 million older adults in 2009

For those over age 80, assistance is needed by 29% of individuals

Senior Pharmacy Facts Adverse drug reactions are among the top five greatest

threats to the health of seniors.

28% of hospitalizations among seniors are due to adverse drug reactions.

32,000 seniors suffer hip fractures each year due to falls caused by medication-related problems.

The elderly account for 12.9% of the U.S. population, but consume approximately 34% of total prescriptions.

On average, individuals 65 to 69 years old take nearly 14 prescriptions per year, individuals aged 80 to 84 take an average of 18 prescriptions per year.

Estimated Annual Costs $76.6 billion among the

ambulatory population

$20 billion in acute-care facilities

$7.6 billion in nursing facilities

Total annual direct medical cost of medication-related problems in the United States:

$104.2 billion

From: American Society of Consultant

Pharmacist Fact Sheet: https://www.ascp.com/articles/about-ascp/ascp-fact-sheet. Accessed May 30, 2012.

The Puzzle: Medicare Medicare Part A

Inpatient hospital

Skilled nursing facility

Medicare Part B

Labs, diagnostics

DME

Medicare Part D

Prescription drug coverage

2012 Beneficiary: Part D Standard Deductible: $320

Individual initial fee: 25% of all costs up to $2930

Initial Coverage Limit: $2930

Coverage Gap (DONUT HOLE): $4700

Catastrophic Coverage: begins after $4700

Part D: Drugs Two Ways

Stand alone PDP (prescription drug plan)

Medicare Advantage Plan with Prescription Drug Coverage: MA-PD

Approved and regulated by Medicare

Designed AND administered by private health insurance

NOT standardized

Formularies, Tiers, Exclusions, Midyear Changes!

Confusion Points Patient’s copays PLUS cost of drug contribute to initial

$2930

Does NOT include monthly premiums

In the News: April 18, 2012

MedPage Today and Circulation: Cardiovascular Quality and Outcomes (April 17 , 2012 issue)

120,000 Medicare patients

Researchers from Harvard Medical School, Boston’s Brigham and Women’s Hospital, and CVS Caremark

“Entering the gap in coverage in which Medicare Part D beneficiaries must pay 100% of their drug costs was associated with a 57% greater risk of discontinuing cardiovascular drugs.”

A bit more detail . . . If extrapolated to the general public . . .

2.9 million Part D beneficiaries discontinuing an additional 117,991 drugs during an average coverage gap of 3.6 months

Reschovsky, James D., and Laurie E. Felland, Access to Prescription Drugs for Medicare

Beneficiaries, Tracking Report No. 23, Center for Studying Health System Change, Washington,

D.C. (March 2009).

Reschovsky, James D., and Laurie E. Felland, Access to Prescription Drugs for Medicare

Beneficiaries, Tracking Report No. 23, Center for Studying Health System Change, Washington,

D.C. (March 2009).

Why the Fuss and Nonsense? Medicare patients

excluded from manufacturer patient assistance programs

Fixed incomes

Chronic conditions with multiple medications

If unable to afford or to take medications . . .

Increased disease state exacerbations

Increased hospitalization rate

Increased risk of loss of independence

Overall, increased costs to health care systems

Next Challenge: Time and the Office Visit 1028 adults

65 years and older

1/3 stated doctors did not review their medications in the past 12 months

http://capsules.kaiserhealthnews.org/index.php/2012/04/doctors-fall-

short-in-helping-many-seniors/

http://www.jhartfound.org/learning-center/hartford-poll-2012/

Challenge!

How do we maintain safe, appropriate, and accurate medication regimens?

What Can We Do? #1: TEAMWORK in the

rural setting

Continuity of care

Communication

Credibility and Trust

Why Pharmacists?

Drugs: It’s What We Do Pharmacists are the medication specialists

Training focuses on entire spectrum of OTCs, herbals, and

prescription drugs

Take a “second look” at a clinical situation

Trained to adjust for therapeutic interchanges

Work with other care providers to meet patient’s needs and wishes

“Tinker” with formularies and look for alternatives

Medications: The Root of all Evil? Medications, in the older adult, associated with:

Confusion

Depression

Falls and fall risks

Disability

Loss of independence

From American Society of Consultant Pharmacists,

https://www.ascp.com/articles/about-ascp/ascp-fact-sheet

Accessed May 30, 2012.

Medication Reviews Multiple Names

MTM: Medication Therapy Management

CMR: Comprehensive Medication Reviews

Aim for an annual medication check-up for each of your patients!

Why MTM? Maximizes therapeutic outcomes through improved

medication use

Reduces the risk of adverse events

Decreases overall health costs

Improves interprofessional interactions

Our Project: Northern Carlton County Medication Management

Partnership with ADRC’s AAAA

$10,000 per year, now in second year

Snapshot: Cloquet, MN Population: 11,201

Population >65: 17%

Median Income: $35,675

www.census.gov. U.S. Census Bureau, 2000 data

Northern Carlton County Community Challenges At Hand

Pre-Seniors and Seniors On Fixed Incomes

Affording Medication

Affording Food, Housing, Utilities, Transportation

Maintaining Fierce Independence

The Practice Site: “A New Era in Regional Healthcare”

Community Memorial Hospital in Cloquet, MN

Critical Access status

25 bed hospital with 88 bed nursing home attached

Specialty Clinics

Pain Clinic

Heme/Onc

Diabetes Ed

Urology

Women’s Health

Orthopedics

And now . . . Comprehensive medication reviews!

Why Now? Why Cloquet? 5414 people over the age of 65 in Carlton County

MTM services not offered by any pharmacy in the immediate area

Medicine Shoppe

Walmart

Thrifty-White Drug

Walgreens (soon to arrive)

Population accustomed to using hospital for extension of care and specialty services

Regional provider of primary care for rural residents

Activities Performed Pre-Prep: review of health care information

Full medication interview, according to patient

Listening to the medication experience

Balancing patient needs and clinical outcomes

Costs vs. risks vs. benefits

The Case of JR 78 y.o. Caucasian male

3 admissions in 40 days

Acute on chronic kidney disease

Increased confusion with medications

Lack of compliance “There’s no need for me to take these pills!”

“My kidneys are just fine as long as I eat beets and greens.”

Implementation of med box fills

Aggressive education campaign: role of meds

JM and Myalgia JM presents upon self-

referral, hearing about the program at the clinic

“I’m always achy and sore, and just want to sleep all the time.”

Medications presented:

HCTZ 25 mg QD

Atenolol 25 mg QD

Lisinopril 5 mg QD

Pravastatin 10 mg QHS

Lovastatin 10 mg QD

Role of double statin therapy?

A Case for Diuresis? MKW MKW is a 64 y.o. former teacher

who presents with increasing incidence of edema.

PMH includes hysterectomy in her 30s, hypertension, hyperlipidemia, diabetes, and labile moods

C.C.: edema, achiness, rising A1c

Current medications:

Estradiol 1 mg QD

Lisinopril 10 mg QAM

Rosuvastatin 20 mg QPM

Gemfibrozil 600 mg BID

Metformin 1000 mg BID

Glipizide XL 10 mg BID

Step 1: Evaluation for necessity of HRT at age 64 and no vasomotor symptoms

Step 2: Identification of interaction between statin and fibrate

Step 3: Increase “tightness” of glucose control

Where Are We Headed Negotiating contracts with 3rd party payers

Working with establishing relationship with Medicare and MTM platform within Part D provisions

Taking the service “on the road” Churches

Assisted living and senior apartments

Senior centers

Community support groups (Parkinson’s, Alzheimer’s)

Take the Program to Them Challenge for Older Americans: Transportation

Initiate instead home visits

Increases comfort level of patient

“Safe” environment

Have access to their records

Encourages individual to prepare

Key Points

Title III-D federal funding wants you as a partner!

Disease state management for at-risk seniors

Medication therapy management has demonstrated benefits in disease state management

Partnering with your community

Expansion of care

Maintained senior independence

Increased patient self-confidence in disease state management

Answers to Quiz Questions 1. D

2. B

3. C

4. D

5. D

Questions? Contact Information:

Megan Undeberg

1110 Kirby Drive

232 Life Science

Duluth, MN 55812

218-726-6039

undeberg@d.umn.edu