This series of blog submissions is devoted to the reasons for and prevention of unnecessary hospitalizations of seniors. As established in the originating blog, the issue of hospitalizations is a significant source of unfavorable outcomes for older adults as well as potentially avoidable medical expense.
Academic research and pilot programs funded by the Centers for Medicare and Medicaid as well as private foundations (not to mention the personal experience of seniors and the knowledge of health care providers) clearly establish why we have avoidable hospitalizations. At the top of the list of reasons is the mismanagement of medications.
The sheer number of medications that seniors take set the stage for errors and omissions that result in adverse events and create a need for hospitalization. Although older adults comprise only 13% of the general population, they account for 34% of all prescription medications and use 30% of all over the counter drugs. Ninety percent of all Medicare beneficiaries take prescription medications and as many as 55% are noncompliant. Almost 40% of seniors are unable to read the prescription label and 76% are unable to understand the information given to them. There is also an issue of multiple doctors prescribing medications for seniors or what is referred to as polypharmacy. There can be a lack of understanding or coordination of the overall medication plan.
One in four home care patients report experiencing one or more symptoms or signs of a problem or complication related to their drug regimen. In one of the most significant studies of the issue, researchers found adverse events occurred in one of five hospital discharges that may lead to readmission (Forster and Clark, Ann Intern Med, 2003, 138:161-167). Another study, Kwany, et al, Arch Intern Med 2007, 167:1034-40, found that 30% of post hospital discharge patients had at least one medication discrepancy presenting potential harm to the patient. These statistics reinforce why adverse drug events add $100B to the nation’s healthcare bill each year.
Recently, my husband was hospitalized due to open heart surgery. The experience we had as patient and family member at the hospital was extremely positive. The only real hiccup came upon discharge. My husband’s physician had informed us the morning of discharge that he would not be going home on Lasix, a drug used to treat fluid retention. When the nurse came to review the post discharge medications with us, he told us that my husband would be continuing to take the Lasix post discharge. When we questioned him and let him know what the doctor had said, the nurse was insistent that the medication had been prescribed. When I asked if he had reviewed the post discharge medication list, he admitted he had not. I asked him to review the list and come back and talk to us once he was appropriately informed. Whereas, this particular incidence would not have actually resulted in an error because the prescription was never written, it did reveal to me how easily miscommunication and confusion can occur.
Medications must be confirmed and reconciled pre, during and post hospitalization. Medication reconciliation is one of the most critical and time consuming services home health nurses provide. The quality of the reconciliation is very important. The reconciliation can be supported or made more difficult by the quality of the transition between the hospital and post acute provider (transition of care is the topic for a future blog entry). Beyond reconciliation, we must help the patient and family with education and the development of an administration plan. Additionally, Medicare home health includes the services of a social worker that can help with resources if the procurement of the medications is a challenge.
The issue of safe medication management is not an easy one to address but, it is one in which all health care providers must be actively involved, individually and collectively. The Home Therapy Safe Steps for Medicationsm is a comprehensive program designed to reduce medication related adverse events including hospitalization. The program is our formal attempt to reduce the obstacles and potentially negative outcomes related to medications.
