Eli's Rehab Report

An occupational therapy referral may help your home care patient manage his medication better.

Everyone on the team can play an important part in improving your home health patients' medication management performance. Try these approaches to some common patient behavior from Carol Siebert, MS, OTR/L, FAOTA with The Home Remedy in Chapel Hill, N.C. and Karen Vance, OTR, supervising consultant with BKD in Colorado Springs, Colo. to help bolster team participation. Read on to find out why your patient may not always be taking the prescribed medication.

Fear and anxiety: If your patient isn't taking all her medications because she is fearful or anxious about addiction or side-effects, allow her to express her concerns. "Fear or anxiety is a legitimate emotional inability to take some or all medications," Siebert and Vance said in the "Medication Management: The Single Most Important ADL" presentation at the National Association for Homecare & Hospice's 2011 Annual Meeting and Exposition.

Financial barriers: In this situation, a referral for nursing to address the fears and provide education on the purpose, effects, and side effects of the medication could help. A referral for the social worker to provide counseling to address the patient's fears and anxiety may also help. In addition, it's a good idea to investigate and rule out financial barriers to this patient taking all her medication.

Difficulty in swallowing: If your patient indicates that he has trouble swallowing his medications, it may be due to dysphagia or a pill-taking method that risks aspiration. Check to see whether the patient is on a dysphagia diet and observe his technique to see if coughing or gagging occur, Siebert and Vance said.

Your patient may benefit from an occupational therapy or speech language pathology consult to evaluate his swallowing and provide dysphagia intervention. You could also check with the pharmacist to see if his medication can be crushed, cut, administered in semi-solids such as applesauce, provided in liquid form, or in a smaller size.

Check cognitive status: If your patient can't keep track of whether she's taken her medications or the pill count shows missing doses, your patient may have a memory disorder. Your first step with this patient is to rule out reversible causes of memory problems such as a urinary tract infection (UTI), medication interactions, overdosing, or use of over-the-counter drugs affecting her cognitive status, Siebert and Vance said. Also assess her for depression and cognitive impairment.

Consult with the physician or pharmacist in regard to UTI, medication interactions, and medications on the Beers list of inappropriate medication use, for this patient. You may also give a referral for OT or SLP to conduct a cognitive assessment and/or provide an alternative storage or dispensing device. Also work with the caregivers to develop strategies to involve the patient in medication administration but minimize the risk of over- or under-dosing.

Accessibility issues: If your patient says it's too much trouble to get to the room where his medication is stored, he has an accessibility problem. To assess for this problem, ask the patient to retrieve his medications rather than having them out prior to your visit, Siebert and Vance said. Observe the retrieval and his endurance, mobility, balance, and reach to successfully retrieve his medication.

Work with the patient and his caregivers to develop options for storing the medications where they are accessible to him at all dosing times, but not accessible to any children, pets, or adults with cognitive impairment in the home. Provide an OT or physical therapy referral to improve his activity tolerance and/or mobility. Provide an OT referral to develop environmental adaptations to optimize medication accessibility.

Don't Just Make a Medication List

An accurate drug regimen review requires the nurse or therapist to sit down with the patient -- to hear and observe, said Siebert. It's not enough for the agency to have the therapist transcribe the meds in a therapy-only case, she said. "People in the back office can't detect issues just from a list."

And not knowing all the side-effects of a patient's medications isn't an excuse to avoid responsibility for the drug regimen review, Vance said. "You don't have to know the side effects ahead of time to be alert and observe changes in the patient. Just noticing a difference and investigating is all we're looking for," she said.

Take Ownership

Everyone on the team has a role in medication management care planning, Siebert said. All skilled clinicians -- including nurses, physical therapists, occupational therapists, and speech language therapists -- should be able to:

• Conduct a drug regimen review.
• Assess the patient's ability to self-administer medications.
• Assess the patient's current medication management including timing and re-stocking.
• Identify needs and make appropriate referrals to other team members to address medication-management related needs.
• Collaborate with the care team to optimize patient's (and/or caregiver's) medication management.

Note: These suggestions were adapted from the Medication Management Care Planning Tool developed by Carol Siebert, MS, OTR/L, FAOTA with The Home Remedy in Chapel Hill, N.C., Karen Vance, OTR, supervising consultant with BKD in Colorado Springs, Colo. and the West Virginia Medical Institute, the Quality Improvement Organization supporting the Home Health Quality Improvement National Campaign.