Coordinating resources for prospective medication risk management of older home care clients in primary care: procedure development and RCT study design for demonstrating its effectiveness.
ABSTRACT: The magnitude of safety risks related to medications of the older adults has been evidenced by numerous studies, but less is known of how to manage and prevent these risks in different health care settings. The aim of this study was to coordinate resources for prospective medication risk management of home care clients ??65 years in primary care and to develop a study design for demonstrating effectiveness of the procedure.Health care units involved in the study are from primary care in Lohja, Southern Finland: home care (191 consented clients), the public healthcare center, and a private community pharmacy. System based risk management theory and action research method was applied to construct the collaborative procedure utilizing each profession's existing resources in medication risk management of older home care clients. An inventory of clinical measures in usual clinical practice and systematic review of rigorous study designs was utilized in effectiveness study design.The new coordinated medication management model (CoMM) has the following 5 stages: 1) practical nurses are trained to identify clinically significant drug-related problems (DRPs) during home visits and report those to the clinical pharmacist. Clinical pharmacist prepares the cases for 2) an interprofessional triage meeting (50-70 cases/meeting of 2 h) where decisions are made on further action, e.g., more detailed medication reviews, 3) community pharmacists conduct necessary medication reviews and each patients' physician makes final decisions on medication changes needed. The final stages concern 4) implementation and 5) follow-up of medication changes. Randomized controlled trial (RCT) was developed to demonstrate the effectiveness of the procedure. The developed procedure is feasible for screening and reviewing medications of a high number of older home care clients to identify clients with severe DRPs and provide interventions to solve them utilizing existing primary care resources.The study is registered in the Clinical Trials.gov ( NCT02545257 ). Registration date September 9 2015.
Project description:OBJECTIVE:To develop a collaborative, person-centred model of clinical pharmacy support for community nurses and their medication management clients. DESIGN:Co-creation and participatory action research, based on reflection, data collection, interaction and feedback from participants and other stakeholders. SETTING:A large, non-profit home nursing service in Melbourne, Australia. PARTICIPANTS:Older people referred to the home nursing service for medication management, their carers, community nurses, general practitioners (GPs) and pharmacists, a multidisciplinary stakeholder reference group (including consumer representation) and the project team. DATA COLLECTION AND ANALYSIS:Feedback and reflections from minutes, notes and transcripts from: project team meetings, clinical pharmacists' reflective diaries and interviews, meetings with community nurses, reference group meetings and interviews and focus groups with 27 older people, 18 carers, 53 nurses, 15 GPs and seven community pharmacists. RESULTS:The model was based on best practice medication management standards and designed to address key medication management issues raised by stakeholders. Pharmacist roles included direct client care and indirect care. Direct care included home visits, medication reconciliation, medication review, medication regimen simplification, preparation of medication lists for clients and nurses, liaison and information sharing with prescribers and pharmacies and patient/carer education. Indirect care included providing medicines information and education for nurses and assisting with review and implementation of organisational medication policies and procedures. The model allowed nurses to refer directly to the pharmacist, enabling timely resolution of medication issues. Direct care was provided to 84 older people over a 15-month implementation period. Ongoing feedback and consultation, in line with participatory action research principles, informed the development and refinement of the model and identification of enablers and challenges. CONCLUSIONS:A collaborative, person-centred clinical pharmacy model that addressed the needs of clients, carers, nurses and other stakeholders was successfully developed. The model is likely to have applicability to home nursing services nationally and internationally.
Project description:<h4>Background</h4>While the home is the most common setting for the provision of palliative care in Australia, a common problem encountered here is the inability of patient/carers to manage medications, which can lead to misadventure and hospitalisation. This can be averted through detection and resolution of drug related problems (DRPs) by a pharmacist; however, they are rarely included as members of the palliative care team. The aim of this study was to pilot a model of care that supports the role of a pharmacist in a community palliative care team. A component of the study was to develop a cost-effective model for continuing the inclusion of a pharmacist within a community palliative care service.<h4>Methods</h4>The study was undertaken (February March 2009-June 2010) in three phases. Development (Phase 1) involved a literature review; scoping the pharmacist's role; creating tools for recording DRPs and interventions, a communication and education strategy, a care pathway and evidence based patient information. These were then implemented in Phase 2. Evaluation (Phase 3) of the impact of the pharmacist's role from the perspectives of team members was undertaken using an online survey and focus group. Impact on clinical outcomes was determined by the number of patients screened to assess their risk of medication misadventure, as well as the number of medication reviews and interventions performed to resolve DRPs.<h4>Results</h4>The pharmacist screened most patients (88.4%, 373/422) referred to the palliative care service to assess their risk of medication misadventure, and undertook 52 home visits. Medication reviews were commonly conducted at the majority of home visits (88%, 46/52), and a variety of DRPs (113) were detected at this point, the most common being "patient requests drug information" (25%, 28/113) and "condition not adequately treated" (22%, 25/113). The pharmacist made 120 recommendations in relation to her interventions.Fifty percent of online survey respondents (10/20) had interacted 10 or more times with the pharmacist for advice. All felt that the pharmacist's role was helpful, improving their knowledge of the different medications used in palliative care. The six team members who participated in the focus group indicated that there were several benefits of the pharmacist's contributions towards medication screening and review.<h4>Conclusions</h4>The inclusion of a pharmacist in a community palliative care team lead to an increase in the medication-related knowledge and skills of its members, improved patients' medication management, and minimised related errors. The model of care created can potentially be duplicated by other palliative care services, although its cost-effectiveness was unable to be accurately tested within the study.
Project description:Home care (HC) clients are increasingly older, have many chronic diseases, and use multiple medicines and thus are at high risk for drug-related problems (DRPs). Establish the sensitivity of practical nurse (PN) administered DRP risk assessment tool (DRP-RAT) compared with geriatrician’s assessment of the medical record. Identify the clinically most significant DRPs needing action. Twenty-six PNs working in HC of Härkätie Health Center in Lieto, Finland, 46 HC clients (≥65 years), and a geriatrician participated in this pilot study. The geriatrician reviewed HC clients’ medications using 3 different methods. The reviews were based on the following: (1) the PN’s risk screening (ie, PN-completed DRP-RAT) and medication list, (2) health center’s medical records, and (3) methods 1 and 2 together. The main outcome was the number of “at-risk patients” (ie, the patient is at risk of clinically significant DRPs) by using each review method. Secondary outcomes were clinically most significant DRP-risk predicting factors identified by the geriatrician. The geriatrician reviewed 45 clients’ medications using all 3 methods. Based on PN-completed DRP-RAT and medication list, 93% (42/45) of the clients were classified as “at-risk patients.” Two other review methods resulted in 45/45 (100%) “at-risk patients.” Symptoms suggestive of adverse drug reactions were the most significant risk predicting factors. Small sample size limits the generalizability of the results. The PN-completed DRP-RAT was able to provide clinically important timely patient information for clinical decision making. DRP-RAT could make it possible to more effectively involve PNs in medication risk management among older HC clients.
Project description:Older people have a higher risk of drug-related problems (DRPs). However, little is known about the prevalence of DRPs in community-dwelling people who screened positive for dementia. Our study aimed to determine (1) the prevalence and types of DRPs and (2) the socio-demographic and clinical variables associated with DRPs in people screened positive for dementia in primary care.The Dementia: life- and person-centered help in Mecklenburg-Western Pomerania (DelpHi-MV) study is a general practitioner (GP)-based cluster-randomized controlled intervention study to implement and evaluate an innovative concept of collaborative dementia care management in the primary care setting in Germany. Medication reviews of 446 study participants were conducted by pharmacists based on a comprehensive baseline assessment that included a computer-based home medication assessment. ClinicalTrials.gov Identifier: NCT01401582.A total of 1,077 DRPs were documented. In 414 study participants (93%), at least one DRP was detected by a pharmacist. The most frequent DRPs were administration and compliance problems (60%), drug interactions (17%), and problems with inappropriate drug choice (15%). The number of DRPs was significantly associated with the total number of drugs taken and with a formal diagnosis of a mental or behavioral disorder.Degree of cognitive impairment (MMSE defined) and formal diagnosis of dementia were not risk factors for an increased number of DRPs. However, the total number of drug taken and the presence of a diagnosis of mental and behavioral disorders were associated with an increased total number of DRPs.
Project description:BACKGROUND:As populations are aging, a growing number of home care clients are frail and use multiple, complex medications. Combined with the lack of coordination of care this may pose uncontrolled polypharmacy and potential patient safety risks. The aim of this study was to assess the impact of a care coordination intervention on medication risks identified in drug regimens of older home care clients over a one-year period. METHODS:Two-arm, parallel, cluster randomized controlled trial with baseline and follow-up assessment at 12?months. The study was conducted in Primary Care in Lohja, Finland: all 5 home care units, the public healthcare center, and a private community pharmacy. PARTICIPANTS:All consented home care clients aged >?65?years, using at least one prescription medicine who were assessed at baseline and at 12?months. INTERVENTION:Practical nurses were trained to make the preliminary medication risk assessment during home visits and report findings to the coordinating pharmacist. The coordinating pharmacist prepared the cases for the triage meeting with the physician and home care nurse to decide on further actions. Each patient's physician made the final decisions on medication changes needed. Outcomes were measured as changes in medication risks: use of potentially inappropriate medications and psychotropics; anticholinergic and serotonergic load; drug-drug interactions. RESULTS:Participants (n?=?129) characteristics: mean age 82.8?years, female 69.8%, mean number of prescription medicines in use 13.1. The intervention did not show an impact on the medication risks between the original intervention group and the control group in the intention to treat analysis, but the per protocol analysis indicated tendency for effectiveness, particularly in optimizing central nervous system medication use. Half (50.0%) of the participants with a potential need for medication changes, agreed on in the triage meeting, had none of the medication changes actually implemented. CONCLUSION:The care coordination intervention used in this study indicated tendency for effectiveness when implemented as planned. Even though the outcome of the intervention was not optimal, the value of this paper is in discussing the real world experiences and challenges of implementing new practices in home care. TRIAL REGISTRATION:ClinicalTrials.gov (NCT02545257). Registered September 9 2015.
Project description:Older adults with multiple chronic conditions face the complex task of medication management involving multiple medications of varying doses at different times. Advances in telehealth technologies have resulted in home-based devices for medication management and health monitoring of older adults. We examined older adults' perceptions of a telehealth medication dispensing device as part of a clinical trial involving home healthcare clients, nurse coordination and use of the medication dispensing device.Ninety-six frail older adult participants who used the medication dispensing device for 12 months completed a satisfaction survey related to perceived usefulness and reliability. Results were analyzed and grouped by themes in the following areas: Ease of Use, Reliability, Medication Management Assistance, Routine Task Performance and Acceptability.Nearly all participants perceived the medication dispensing device as very easy to use, very reliable and helpful in the management of their medications. Eighty-four percent of participants expressed a desire to use the machine in the future.The technology-enhanced medication management device in this study is an acceptable tool for older adults to manage medication in collaboration with home care nurses. Improved usability and cost models for medication dispensers are areas for future research.
Project description:The Drug-Associated Risk Tool (DART) has been developed as a self-administered questionnaire for patients with the aim of stratifying patients according to their risk of drug-related problems (DRPs). We aimed to validate the ability of the questionnaire to distinguish between hospitalised patients showing lower and higher numbers of DRPs.Cross-sectional study assessing the questionnaire's concurrent criterion validity.Five geriatric and the associated physical and neurological rehabilitation wards of a Swiss regional secondary care hospital with 617 beds.We recruited 110 patients from a total of 437 admissions. Exclusion criteria were insufficient knowledge in spoken or written German, medical conditions preventing meaningful conversations and already receiving pharmacy services.Comprehensive pharmacist-led clinical medication reviews were performed, including patient interviews, to identify potential and manifest DRPs. A cluster analysis was conducted to assess the discriminatory potential of the DART to group patients according to number (low and high) of identified DRPs. A subsequent discriminatory function analysis was performed to reduce the number of items. We determined which DART items may be used to trigger what type of medication review.Recruited patients had a median age of 79 years and were prescribed a median of 11 drugs. Patients with a median DART score of 10 and a median of 3 DRPs represented one cluster, whereas patients with a median DART score of 15 and a median of 8 DRPs represented another cluster. Discriminatory function analysis reduced the questionnaire to five items with a moderate to strong correlation with the number of DRPs per patient (Spearman's rank correlation ?=0.44). Additional items were associated with patients benefiting from interviews.As a self-administered questionnaire for patients, the DART may be used to stratify hospitalised non-acute older patients in groups of having low and high likelihood of DRPs. The analyses showed that a short form of the DART can be used instead of the full tool to identify older inpatients at risk for DRPs. Additional eight items from the DART may be used to initiate additional clinical pharmacy services. The linkage between certain DART questions and type of medication review enables pharmacist resource allocation.
Project description:Patients are at risk of drug-related problems (DRPs) at transition points during hospitalization. The community pharmacist (CP) is often the first healthcare professional patients visit after discharge. CPs lack sufficient information about the patient and so they may be unable to identify problems in medications, which may lead to dispensing the wrong drugs or dosage, and/or giving wrong information. We aim to assess the impact of a complex intervention comprising of medication reconciliation performed at discharge by a hospital pharmacist (HP) with communication between the HP and CP on DRPs during the seven days following discharge.The study is a cluster randomized crossover trial involving 46 care units (each unit corresponding to a cluster) in 22 French hospitals during two consecutive 14-day periods, randomly assigned as 'experimental' or 'control' (usual care) periods. We will recruit patients older than 18 years of age and visiting the same CP for at least three months. We will exclude patients with a hospital length of stay of more than 21 days, who do not return home or those in palliative care. During the experimental period, the HP will perform a medications reconciliation that will be communicated to the patient. The HP will inform the patient's CP about the patient's drug therapy (modification in home medication, acute drugs prescribed, nonprescription treatments, and/or lab results). The primary outcome will be a composite outcome of any kind of drug misuse during the seven days following discharge assessed at day seven (±2) post-discharge by a pharmacist in charge of the study who will contact both patients and CPs by phone. The secondary outcome will be unplanned hospitalizations assessed by phone contact at day 35 (±5) after discharge. We plan to recruit 1,176 patients.This study will assess the impact of a reconciliation of medications performed at patient discharge followed by communication between the HP and the patient's CP. It will allow for identifying the type of patients in France for which the intervention is most relevant.This study was registered with ClinicalTrials.gov (number: NCT02006797) on 5 December 2013.
Project description:Background:Syrian refugees residing in Jordan suffer from chronic illnesses, low quality of life (QoL) and anxiety. Pharmacists delivering the medication review service can have a role in improving this growing worldwide problem. Objectives:To assess the effect of the medication review service on QoL and anxiety scores for Syrian refugees living with chronic medical conditions. Methods:This randomized single-blinded intervention control study was conducted in Jordan. Syrian refugees were recruited and randomized into intervention and control groups. Two home visits were organized with each participant, at baseline and three months later. The medication review service was delivered to the participants and questionnaires regarding QoL and anxiety were completed by all participants. As a part of the medication review service, drug-related problems (DRPs) were identified by a clinical pharmacist for all patients, but recommendations to resolve these DRPs were delivered to intervention group refugees' physicians only (control group patients did not receive this part of the service till the end of the study); DRPs were corrected and pharmacist-delivered counseling and education were provided as well. At follow-up, DRPs assessment, QoL and anxiety scores were assessed for refugees in the intervention and control groups. Results:Syrian refugees (n=106) were recruited and randomized into intervention (n=53) and control (n=53) groups with no significant difference between both groups at baseline. The number of medications and diagnosed chronic diseases per participant was 5.8 (SD 2.1) and 2.97 (SD 1.16), respectively. At follow-up, a significant decrease in the number of DRPs for refugees in the intervention group was found (from 600 to 182, p<0.001), but not for the control group (number stayed at 541 DRPs, p=0.116). Although no significant difference between the groups was found with regards to QoL at follow-up (p=0.266), a significant difference was found in the anxiety scores between the groups (p<0.001). Conclusion:The medication review service delivered by clinical pharmacists can significantly improve refugees' DRPs and anxiety scores. As for QoL, significant improvements can be seen for all refugee patients, regardless of whether the DRPs identified were resolved or not.
Project description:INTRODUCTION:Managing medication regimens is one of the most complex and burdensome tasks performed by older people, and can be prone to errors. People living with dementia may require medication administration assistance from formal and informal caregivers. Simplified medication regimens maintain the same therapeutic intent, but have less complex instructions and administration schedules. This protocol paper outlines a study to determine the feasibility of a multicomponent intervention to simplify medication regimens for people receiving community-based home care services. METHODS AND ANALYSIS:This is a non-randomised pilot and feasibility study. Research nurses will recruit 50 people receiving community-based home care services. All participants will receive the intervention from a clinical pharmacist, who will undertake medication reconciliation, assess each participant's capacity to self-manage their medication regimen and apply a structured tool to identify opportunities for medication simplification. The pharmacist will communicate recommendations regarding medication simplification to registered nurses at the community-based home care provider organisation. The primary outcome will be a description of study feasibility (recruitment and retention rates, protocol adherence and stakeholder acceptability). Secondary outcomes include the change in number of medication administration times per day, medication adherence, quality of life, participant satisfaction, medication incidents, falls and healthcare utilisation at 4 months. ETHICS AND DISSEMINATION:Ethical approval was obtained from the Monash University Human Research Ethics Committee and the community-based home care provider organisation's ethical review panel. Research findings will be disseminated to consumers and caregivers, health professionals, researchers and healthcare providers through the National Health and Medical Research Council Cognitive Decline Partnership Centre and through conference presentations, lay summaries and peer-reviewed publications. This study will enable an improved understanding of medication management and administration among people receiving community-based home care services. This study will inform the decision to proceed with a randomised controlled trial to assess the effect of this intervention. TRIAL REGISTRATION NUMBER:ACTRN12618001130257; Pre-results.