Penny H. Feldman

Possible Medication Errors in Home Healthcare Patients

OBJECTIVE: To determine the frequency of possible medication errors in a population of older home healthcare patients according to expert panel objective criteria.

An intervention study to enhance medication compliance in community-dwelling elderly individuals.

OBJECTIVEnTo determine whether daily videotelephone or regular telephone reminders would increase the proportion of prescribed cardiac medications taken in a sample of elderly individuals who have congestive heart failure (CHF).nnnMETHODSnThe authors recruited community-dwelling individuals age 65 and older who had the primary or secondary diagnosis of CHF into a randomized controlled trial of reminder calls designed to enhance medication compliance. There were three arms: a control group that received usual care; a group that received regular daily telephone call reminders; and a group that received daily videotelephone call reminders. Compliance was defined as the percent of therapeutic coverage as recorded by Medication Event Monitoring System (MEMS) caps. Subjects were recruited from 2 sources: a large urban home health care agency and a large urban ambulatory clinic of a major teaching hospital. Baseline and post-intervention MOS 36-Item Short-Form Health Survey (SF-36) scores and Minnesota Living with Heart Failure (MLHF) scores were obtained.nnnRESULTSnThere was a significant time effect during the course of the study from baseline to post-intervention (F[2,34] = 4.08, p < .05). Over time the elderly individuals who were called, either by telephone or videotelephone, showed enhanced medication compliance relative to the control group. There was a trend, but no significant difference between the two intervention groups. Both SF-36 and MLHF scores improved from baseline to post-intervention for all groups. There was no significant change in the SF-36 scores for the sample, but there was a significant change for the MLHF scores (p < .001). The control group had a significant fall off in the medication compliance rate during the course of the study, dropping from 81% to 57%.nnnCONCLUSIONSnTelephone interventions are effective in enhancing medication compliance and may prove more cost effective than clinic visits or preparation of pre-poured pill boxes in the home. Technologic advances which enable clinicians to monitor and enhance patient medication compliance may reduce costly and distressing hospitalization for elderly individuals with CHF.

Translating research into practice: transitional care for older adults

RATIONALEnOver the last decade, in order to close the safety and health care quality chasm, there has been a growing imperative to translate evidence-based research into practice.nnnAIMS AND OBJECTIVESnThis study examines the major facilitators and barriers of implementing in a large US insurance organization - Aetna Corporation - an evidence-based model of care, the Transitional Care Model, which has been rigorously tested over the past twenty years by a multidisciplinary team at the University of Pennsylvania.nnnMETHODSnSemi-structured interviews of 19 project leaders, case managers, and transitional care nurses were conducted during two phases of translation - start-up and roll out. Qualitative analysis was used to identify more than a dozen key barriers to and facilitators of translation in these two critical phases. Results Six facilitators and seven barriers that are consistent with the literature were identified during and categorized as either start-up or roll-out.nnnCONCLUSIONnThe combined results have important practical implications for other, subsequent translational efforts and for assisting providers, policy makers, payers, and other change agents in integrating evidence-based practice with real world management.

Improving Medication Use in Newly Admitted Home Healthcare Patients: A Randomized Controlled Trial

OBJECTIVES: To test the efficacy of a medication use improvement program developed specifically for home health agencies. The program addressed four medication problems identified by an expert panel: unnecessary therapeutic duplication, cardiovascular medication problems, use of psychotropic drugs in patients with possible adverse psychomotor or adrenergic effects, and use of nonsteroidal antiinflammatory drugs (NSAIDs) in patients at high risk of peptic ulcer complications. It used a structured collaboration between a specially trained clinical pharmacist and the patients home‐care nurses to improve medication use.

Automating the medication regimen complexity index

Objective To adapt and automate the medication regimen complexity index (MRCI) within the structure of a commercial medication database in the post-acute home care setting. Materials and Methods In phase 1, medication data from 89u2005645 electronic health records were abstracted to line up with the components of the MRCI: dosage form, dosing frequency, and additional administrative directions. A committee reviewed output to assign index weights and determine necessary adaptations. In phase 2 we examined the face validity of the modified MRCI through analysis of automatic tabulations and descriptive statistics. Results The mean number of medications per patient record was 7.6 (SD 3.8); mean MRCI score was 16.1 (SD 9.0). The number of medications and MRCI were highly associated, but there was a wide range of MRCI scores for each number of medications. Most patients (55%) were taking only oral medications in tablet/capsule form, although 16% had regimens with three or more medications with different routes/forms. The biggest contributor to the MRCI score was dosing frequency (mean 11.9). Over 36% of patients needed to remember two or more special instructions (eg, take on alternate days, dissolve). Discussion Medication complexity can be tabulated through an automated process with some adaptation for local organizational systems. The MRCI provides a more nuanced way of measuring and assessing complexity than a simple medication count. Conclusions An automated MRCI may help to identify patients who are at higher risk of adverse events, and could potentially be used in research and clinical decision support to improve medication management and patient outcomes.

The Preferences for Everyday Living Inventory: Scale Development and Description of Psychosocial Preferences Responses in Community-Dwelling Elders

PURPOSE OF THE STUDYnAssessing preferences for daily life is the foundation for person-centered care delivery. This study tested a new measure, the Preferences for Everyday Living Inventory (PELI), with a large sample of community-dwelling older adults. We sought to evaluate the tools convergent and divergent validity, identify the most commonly held preferences within the sample, and explore relationships between gender and race and strength of preferences.nnnDESIGN AND METHODSnRandomly selected African American and Caucasian home health agency clients (N = 437) were interviewed using the PELI. Respondents self-reported functional ability, physical health, affect, mental health, and five domains of psychosocial preferences. The study examined correlations among descriptive variables and preference items and used logistic regression to estimate relationships between gender and race and 55 PELI items and 10 descriptive covariates.nnnRESULTSnThe study found support for the PELIs construct validity, identified seniors most strongly held preferences across domains, and revealed significant differences in preferences by gender and race.nnnIMPLICATIONSnThe PELI captures strongly held personal preferences and shows promise as a practical tool that allows providers to document client preferences and customize care accordingly.

A Randomized Intervention to Improve Heart Failure Outcomes in Community-Based Home Health Care

ABSTRACT This study examines the effects of a home health intervention designed to standardize nursing care, strengthen nurses support for patient self-management and yield better CHF patient outcomes. Participants were 371 Medicare CHF patients served by 205 nurses randomized to intervention and control groups in a large urban home health care agency (HHA). The intervention consisted of an evidence-based nursing protocol, patient self-care guide, and training to improve nurses teaching and support skills. Outcome measures included home care, physician and emergency department (ED) use, hospital admission, condition-specific quality of life (QoL), satisfaction with home care services and survival at 90 days. The intervention was associated with a marginally significant reduction in the volume of skilled nursing visits (p = .074), and a reduction variation in the typical number of visits provided (p < .05), without a significant increase in physician or ED use or patient mortality. Hypothesized improvement in other outcomes did not occur.

Improving Blood Pressure Control: Results of Home-based Post-acute Care Interventions

BackgroundBlood pressure (BP) control remains elusive for many Americans. Although home health nurses are uniquely positioned to help vulnerable individuals achieve BP control, hypertension (HTN) management has not been a high priority in post-acute care.ObjectiveTo examine the effects of two home-based interventions designed to improve BP outcomes among high-risk African-American patients.DesignCluster randomized controlled trial.ParticipantsA total of 845 newly admitted patients with uncontrolled HTN (JNC7 stages 1 or 2).InterventionsThe “basic” intervention delivered key HTN information to clinicians and patients, and a home BP monitor to patients, while the patients received usual post-acute care. The “augmented” intervention provided more intensive and extensive HTN information, monitoring and feedback for 3xa0months beyond the index home care admission.MeasuresPrimary: BP control. Secondary: reductions in mmHG SBP and DBP, improvements in proportions improving JNC7 stage or achieving clinically meaningful reductions in SBP and DBP.MethodsMultivariate regression models.Key ResultsThe basic intervention produced no significant BP improvements; the augmented intervention significantly improved stage 2 patients’ outcomes. Among stage 2 patients, the augmented intervention increased BP control by 8.7 percentage points relative to usual care (8.9% vs. 17.6%; pu2009=u20090.01), yielded an 8.3 mmHG relative reduction in SBP (pu2009=u20090.01), and increased the proportion achieving at least a 20 mmHG reduction in SBP by 16.4 percentage points (pu2009=u20090.01).ConclusionAmong stage 2 patients, a nurse-led intervention providing additional HTN medication review and patient self-management support during the 3-month post-acute care period yielded significant improvements in 3-month BP control, plus improvements in secondary BP outcomes.

Sustainability of Partnership Projects: A Conceptual Framework and Checklist

BACKGROUNDnThere is growing recognition that the health care delivery system in the United States must make major changes. Intervention projects focusing on quality and patient safety offer the potential for reshaping the future of medicine. Sustainability of the Partnerships for Quality (PFQ) projects and other patient safety and quality improvement projects that provide evidence of effectiveness is essential if progress is to be made.nnnMETHODSnFor the purposes of these projects, a conceptual framework and a checklist for sustainability were developed. The framework consists of two dimensions: (1) the goals--what is to be sustained--and (2) elements for sustainability--infrastructure, incentives, incremental opportunities for involvement, and integration. The checklist is designed to trigger planning for sustainability early in a projects design. Specific questions about each of the elements can cue planners and project leaders to build in the goals for sustainability and change processes.nnnRESULTSnA pilot test showed that the framework and checklist are relevant and helpful across a variety of projects.nnnDISCUSSION AND CONCLUSIONnTwo extended examples of planning and action for sustainability from the PFQ projects are described. It is too early to claim sustainability for these project. However, continued monitoring for at least three years with the checklist could result in valuable national data with which to design and implement future projects.

Home-Based Blood Pressure Interventions for Blacks

Efforts to increase blood pressure (BP) control rates in blacks, a traditionally underserved high-risk population must address both provider practice and patient adherence issues. The home-based BP Intervention for blacks study is a 3-arm randomized controlled trial designed to test 2 strategies to improve hypertension management and outcomes in a decentralized service setting serving a vulnerable and complex home care population. The primary study outcomes are systolic BP, diastolic BP, and BP control; secondary outcomes are nurse adherence to hypertension management recommendations and patient adherence to medication, healthy diet, and other self-management strategies. Nurses (n=312) in a nonprofit Medicare-certified home health agency are randomized along with their eligible hypertensive patients (n=845). The 2 interventions being tested are (1) a basic intervention delivering key evidence-based reminders to home care nurses and patients while the patient is receiving traditional postacute home health care; and (2) an augmented intervention that includes that same as the basic intervention, plus transition to an ongoing Hypertension Home Support Program that extends support for 12 months. Outcomes are measured at 3 and 12 months after baseline interview. The interventions will be assessed relative to usual care and to each other. Systems change to improve BP management and outcomes in home health will not easily occur without new intervention models and rigorous evaluation of their impact. Results from this trial will provide important information on potential strategies to improve BP control in a low-income chronically ill patient population.