OASIS Alert

If medication management isn’t at the top of your “to do” list, state surveyors, fiscal intermediaries, JCAHO and even John Q. Public will want to know why.

Home health agencies that aren’t focusing on issues related to management of oral medications might want to re-think that, suggests Chapel Hill, NC-based senior  consultant Judy Adams with LarsonAllen Health Care Group.

Oral medication management is “definitely addressed in the enhanced survey process,” Adams warns. And “stabilization in management of oral medications” is one of the  outcomes the Centers for Medicare & Medicaid Services proposes to include in its publicly reported home health outcomes, she reminds providers.

The Joint Commission on Accreditation of Healthcare Organizations focuses on medication management, especially drug/drug and food/drug interactions, reports North  Andover, MA-based consultant Maureen Yadgood. New medication management standards take effect in 2004, and home health conditions of participation require  medication teaching and management, she adds.

Medication management already is a primary activity for most home health nurses, contends Bob Ferry of Reno, NV-based Home Care Plus, but its complexity adds to the  challenge. The patient needs to be taking the right medications, in the right dose, at the right time — consistently.

Critical areas for HHAs’ attention include:

1. Accurately answering OASIS question M0780. This question requires the clinician to determine if the patient can prepare and take all the prescribed oral medications  safely and reliably, including taking the correct dose at the appropriate time.

A critical component of being able to manage her own medications is a patient’s ability to sequence information, Ferry cautions. His agency’s nurses administer a  five-minute test to determine if the patient can follow directions and monitor her own behavior before deciding how much intervention she’ll need, he explains.

Nurses should use both observation and interview approaches to determine the accurate answer for M0780, experts agree. Watch the patient prepare the medication. Can  she open the containers? Question her about the times and dosage. Is she confused or inconsistent? “Apply your assessment skills, don’t just perform a survey,” Ferry  urges.

And don’t confuse willingness with ability, Adams advises. While being willing to take the med and choosing to take it as prescribed are important parts of medication  management, those are not the parts addressed by the OASIS assessment. Instead, determine if the patient can physically and mentally manage the meds either on her  own or if someone prepares them in advance, she says.

2. Identifying and preventing duplicate drugs and harmful drug interactions. Patients frequently consult several doctors and may receive the same medication from more than  one doctor, Ferry explains. Nurses need to check with the patient on every visit to determine whether she has any new medicines or changes in dosage or timing, he says.

Many agencies subscribe to a databank for drug information and either consult it manually or have it connected to their laptops or PDAs, Yadgood reports. Often HHAs will  have a pharmacist on their board to alert them to drug issues and review medication policies. Others pay a consulting pharmacist for assistance, she says.

Patients taking multiple medications for a variety of chronic conditions, or those suffering falls may benefit from a program developed by the Partners in Care Foundation in  Burbank, CA. This program, funded by the Hartford Foundation and conducted with the help of Vanderbilt University and the Visiting Nurse Associations in California and New  York, assists agencies by identifying high-risk patients using an algorithm tied to an agency’s database, program director and pharmacist Dennee Frey tells Eli.

3. Addressing outcome-based quality improvement and survey issues. In the enhanced survey process, the surveyor is instructed to check the agency’s rating on  improvement in management of oral medications, Adams reminds HHAs. If the agency is 10 percent lower than the national reference, the surveyor must conduct home  visits and/or record reviews in this area.

And having at least 30 patients showing “discharge to the community needing medication assistance” — a Tier 2 adverse event — may trigger surveyor scrutiny, Adams adds. This could inadvertently happen if clinicians mistakenly assess whether the patient is managing her medications rather than if she can manage them, Yadgood says.

4. Investigating adaptive approaches to improve patient compliance. Nurses spend considerable time educating patients and caregivers about medications and ways to  manage them, Adams says, and new approaches constantly arise. Some are simple reminders such as plastic or homemade containers with sections for each day or time of day, or charts for the patient to check off.

Requesting easy to open containers from the pharmacy or using varying numbers of elastic bands on pill containers can help patients with finemotor or visual difficulties be  independent, Adams suggests. Family members, friends or neighbors also can pre-fill containers, and alarms can remind patients when the next dose is due, she adds.