Improving Primary Care Medication Patient Safety: System-level Medication Adherence Issues Marie Smith, PharmD Professor and Asst. Dean, Practice and Public Policy Partnerships Meg Mello Moniz, PharmD Research Assistant University of Connecticut School of Pharmacy National Quality Colloquium Boston, MA 8-17-11
Topic Overview Dimensions of Adherence CMS Medicaid Transformation Grant: Adherence Lessons Primary Care Medical Home MTM* Program Hospital-to-Home Care Transition MTM Program Practical Recommendations * MTM = Medication Therapy Management
5 Dimensions of Adherence
Common Barriers to Medication Adherence Poor provider patient communication Poor understanding of the disease, treatment plan Poor understanding of the proper use of medication Physician prescribes overly complex regimen Medication beliefs or adverse drug events PATIENT HEALTH PROVIDERS Poor access or missed appts Poor access to medications Poor quality of medical care Switching to a different formulary High medication costs HEALTH SYSTEM Lack of care transition coordination Poor knowledge of drug costs Poor knowledge of formulary Low level of job satisfaction Osterberg, L and Blaschke, T. Adherence to Medication; N Engl J Med 2005;353:487-97.
Pharmacist MTM in PCMH Patient-Network Pharmacist visit in PCMH between provider visits Initial visit + 5 monthly follow-up visits Integrate Data sources: Patient EHR Rx Claims Report Assessment: multiple chronic conditions and medications for discrepancies and medication-related problems over 6 month period MTM EVIDENCE-BASED REPORTS Comprehensive Med List Medication Action Plan CARE COORDINATION Via EHR MTM Summary Report w/ Recommendations Patient/Caregiver PCP and Specialists Home Nurse Dispensing Pharmacist FUNDING SOURCE: CT DSS Medicaid Transformation Grant PROJECT TEAM: UConn School of Pharmacy, CT Pharmacists Assn 5
Key Findings CT Medicaid beneficiaries have complex medication regimens Medical conditions ~9-10/ptnt, chronic medications ~ 15-16/ptnt Pain, GI, Dyslipidemia, HBP, Asthma/COPD, Diabetes, Depression Mean Age 51 yrs, Female 71% 410 patient visits, 88 patients, 20 providers in 5 primary care sites Medication discrepancies (n= 3248) inconsistency in the drug, dose, frequency, route, quantity dispensed, or current medication use by the patient between the Medicaid claims, EHR medication list, or patient s report of actual medication use at home. 50%-discontinued meds (by prescriber or patient); 39% - drug or dose Medication-related problems (MRPs) = 917, mean = 10.4/ptnt Medication appropriateness (30%) Needs additional medications (23%) using evidence-based guidelines Effectiveness (23%) - Dose too low (16%) Safety (21%) - Adverse drug event (16%) Patient non-adherence (26%) Patient doesn t understand med n use instructions (11%) esp. inhalers 74% MRPs relate to clinical decision-making / team-based care 26% MRPs relate to patient health beliefs, adherence behaviors 6
Adherence Trends Patients disclosed authentic adherence issues to the pharmacist after 3-4 visits; initially told pharmacists what they wanted to hear until they established a trusted patient-provider relationship Modified Morisky Questionnaire (8-items) SCORES: <2 = High adherence behaviors >2 = Low adherence behaviors Morisky Results (60 patients with initial and final visit scores) a paired t test of mean difference Took 3-4 patient-pharmacist visits for authentic med adherence issues Face-to-face visits established a trusted patient-pharmacist relationship 7
Pharmacist MTM Care Transition Patient-Network Pharmacist Home Visit within 72 hrs Hospital Discharge phone follow-up at 30 days post-discharge Patient Integrate Data sources: Discharge Info Rx Claims Report Assessment: medications for discrepancies and medication-related problems MTM EVIDENCE-BASED REPORTS Comprehensive Med List Medication Action Plan CARE COORDINATION Via EHR MTM Summary Report w/ Recommendations Patient/Caregiver PCP and Specialists Home Nurse Dispensing Pharmacist FUNDING SOURCE: CT DSS Medicaid Transformation Grant PROJECT TEAM: UConn School of Pharmacy, CT Pharmacists Assn 8
Hospital-to-Home Care Transition: A Case Study 68 year-old female admitted to hospital with a low blood sugar level and slow heart rate due to adverse drug events with high-risk medications and a drug interaction between two medications. Pharmacist home visit within 48 hrs of discharge: Resolved 7 discrepancies between the discharge medications, prescribed preadmission medications that should be discontinued or restarted, and OTC medication that the patient may not have reported to all providers. Coordinated medication care with the patient, primary care provider, a specialist, home care nurse, and dispensing pharmacist that involved high-risk medications (cardiac medications, insulin), and Medicaid coverage issues for eye drop medications. Developed a reconciled comprehensive active medication profile and a Medication Action Plan for the patient that had directions for the updated medication regimen of 3 new, 5 continued, and 4 discontinued medications. Provided a written MTM summary of the home visit with a comprehensive, active medication profile and recommendations for optimal medication therapy and avoidance of drug therapy problems to the patient s primary care provider and a specialist (ophthalmologist).
Hospital-to-Home Care Transition Case Study: System-level Adherence Issues 1. Missing medications A new medication noted on the discharge instructions but no prescription was given to the patient Two critical pre-admission medications overlooked upon discharge causing confusion on whether or not they should be continued once patient was at home 2. Prior authorization (PA) Cosopt (eye drop combination product) required a PA; physician office did not complete PA paperwork so patient received 2 separate eye drop products Patient became confused and only took one of the two prescribed eye medications Pharmacist called MD office to explain that PA for Cosopt would help patient 3. Automatic Refills Two months after discharge, the patient received a medication through an auto-refill program; the auto-refill medication was discontinued (patient had adverse drug event that led to hospital admission) Patient realized that the auto-refill medication was not listed on her Medication Action Plan; called pharmacist to confirm she should not take this medication Patient called pharmacy to be removed from auto-refill program
Practical Recommendations 1. Pharmacist MTM services promote quality-driven, safe, cost-effective, culturally appropriate, and person- and family-centered care. - holistic view of patient s drug therapy problems across multiple disease states - starts with med reconciliation and comprehensive review of all meds (across multiple prescribers and multiple pharmacies) - uses tool for patient engagement and self-management (Medication Action Pan) - communicates recommendations to prescribers to prevent medication errors (MTM report) - recommends simpler, cost-effective medication regimens - promotes coordinated, collaborative team-based care for all patient s health professionals 2. MTM services with a face-to-face meeting between the patient and pharmacist builds a trusting relationship that can discover real adherence barriers. - may take several interactions for patient to reveal authentic reasons for non-adherence 3. Medication regimen changes by the prescriber needs to be communicated in real-time to the patient s pharmacist. - we use ERx for new and refill prescriptions, so why not use ERx for meds that are stopped or discontinued? dose adjustments with existing medication? - avoid use of auto-refill programs for discontinued meds or meds with adverse events - promote shared health information data through secure health information exchange (HIE)
RESOURCES National Priorities Partnership/NEHI http://www.nehi.net/publications/ Compact Action Briefs: Improving Medication Adherence Preventing Medication Errors CT Medicaid MTM Medical Home Project Health Affairs, April 2011(p.646-654) Email: marie.smith@uconn.edu