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Medication management may be one of the greatest clinical challenges in senior living, where the average resident may take four to six medications a day, or more. Yet the assisted living business has earned a reputation for consistent positive performance in this arena.
"A major reason people move into assisted living is that they need help with medications, so it is a service we take very seriously," says Maribeth Bersani, ALFA's senior vice president for public policy. "We are training people, we are monitoring them, we are doing it safely and doing it well."
The numbers bear it out. Looking at all medication mistakes with the exception of time errors, assisted living shows an error rate of 8.2 percent versus 10 percent in hospitals, according to Heather M. Young, Ph.D. and GNP, et al. in their paper, Types, Prevalence, and Potential Clinical Significance of Medication Administration Errors in Assisted Living.
It takes a range of best practices for assisted living providers to score consistently high in the realm of medication management.
Internal Vigilance
Some 1.5 million people receive the wrong medication or the incorrect dose each year, according to the Institute of Medicine, part of the National Academies of Science. Yet assisted living has a history of positive procedures that help ensure accurate dosing, of-ten in response to systemic causes that originate outside assisted living.
Sandi Flores, RN points to poly-pharmacy as one example. "One of the major factors is the sheer number of meds our residents are taking," says Flores, director of clinical services for Senior Resource Group.
To keep a handle on poly-pharmacy, assisted living communities implement a range of protocols, according to a survey conducted recently for the Center for Excellence in Assisted Living (CEAL). The survey found that 74 percent of assisted living providers make sure doctors or registered nurses review lab data for residents; 68 percent use consultant pharmacists, and 67 percent use blister cards or pillow packs from primary pharmacies. This type of packaging is a safeguard to ensure residents receive correct medication dosage.
Transitions also may be an issue, a time when drugs or orders can get mishandled on their way to the assisted living community. "The biggest problem we have found is when a resident is transferred [into assisted living]," says Loretta Kaes, RN , vice president of health services for Chelsea Senior Living.
Safeguards begin with a vigilant nursing staff, Kaes says. "I want the nurses to question the orders. If you see a resident on 23 medications, I want the nurse to ask which of these drugs possibly are overmedicating," she says. Nurses likewise make it a point to reconcile the medications as delivered against those as prescribed.
New models also are emerging. Kaes has served with the Health Care Association of New Jersey, which has developed an even more streamlined system. The group has urged doctors to communicate directly with pharmacies, reducing the possibility of error and saving the nurse one step. "Otherwise, you spend 18 hours a day trying to chase the doctor down" in search of clarification, Kaes says.
Rise of the Med Tech
One of the most promising, and most effective, evolutions in medication management has been the rise of the medication technician, or med tech for short. Also known as trained, unlicensed assistive personnel (UAP), these individuals are authorized to deliver medications, freeing nurses to pursue other tasks. The use of UAPs is allowed in virtually every state. These valuable personnel are enabled to do a variety of tasks depending on the state, and are required to attain certain types and levels of training, again varying by state.
In the realm of medication management, "UAPs generally do remarkably well with this complex task. The bulk of the medications are low risk and routine, and the risks appear to be minimal," Young writes.
While some states are questioning the use of UAPs, a growing body of evidence suggests med techs are an effective means for assisted living to maintain its high level of medical management assurance. "Where it is allowed, which is in most states, it is working very effectively," Bersani says.
Success lies in training, not merely an introduction to "how" things are done, but also a view toward why. "These are intelligent people, you can't just teach them a task. You teach them the rationale behind things, and that is when you see an increase in performance," Flores says. With an understanding of not just how but why, "people are much more understanding of proper dosing, proper timing, and so on."
To ensure information sticks, Flores issues hands-on testing in multiple topics. The student also must make three perfect passes under supervision before being allowed to fly solo. Delivering training throughout this nationwide organization relies in part on quarterly webinars, which Flores creates.
One more winning strategy for utilizing med techs: Dress the part. Many will think it is a small point, but Flores insists that uniforms for medication aids lead directly to fewer errors. "They are recognized as being something special, and so they act like something special," she says.
Systemic Strategies
Underlying all these basic strategies, successful administrators demonstrate a commitment to a systematic approach to medication management. To get the right drugs and dosages into the right hands at the right time, appropriate systems must be in place and safety protocols must always be consistent and repeatable.
Best systemic practices in medication management cover a lot of ground. Strategies can be incredibly detailed. A few that are absolutely worth implementing include the following:
Get stakeholders involved. Staff, physicians, and pharmacists all should have a chance to offer input into the plan, since they will be the ones to put it in practice. Transfers are crucial. Check the labels of everything coming from home or from the hospital. Read back phone orders and don't hang up without verbal verification. If a resident is self-administering, confirm every quarter that the resident is still capable of the task. "Success comes from having the right systems and protocols in place," Kaes says. "By constantly reviewing and observing those who dispense medications, it allows us to ensure that people are getting the right medications in the right manner."
The biggest and broadest effort has to do with handling procedures among the staff: where and how medicine is received, stored, and dispensed. Every residence will do this differently. So long as the procedure is easy to understand and simple to implement, the "how" will matter less than the assurance that the internal system is solid. It must be repeatable, and must be repeated consistently time after time.
Some add a further step: Ongoing auditing. It's just one more way to ensure accuracy, says Patricia Foran, president of C.O.R. Services, a consultancy to the senior housing industry.
Foran has been on the front lines, having served as a vice president at Benchmark Assisted Living prior to becoming a consultant to multiple assistant living communities. Looking at the situation from all sides, she says auditing is a significant tool in keeping errors in check.
Given the possibility of human error, "you need to have somebody to physically monitor what is going on," she says. In Virginia and elsewhere, the executive director has to be certified in medication management, so there's a built-in auditor. Outside consultants also can play that role.
In a typical audit, "we are literally asking people to go on a med pass, and watching how the practice is being performed. Then you finetune it each time," Foran says. "You need to do this no less than quarterly."
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In the best examples, assisted living residences have looked beyond their own internal resources, getting families involved for cooperative efforts in such realms as co-pays and drug availability.
"I think the families have to be really aware that their family member is in a plan that covers all their drugs," says Jody Silva Falk, vice president of client services at Chem Rx, a pharmacy serving about 30 assisted living residences. "They need to know their formulary changes every year and they need to stay on top of that. They need to take a proactive role in what's going on with mom's coverage."
In addition to family participation, combined with skillful management of the human elements within the community, technological aids can simplify and safeguard various tasks on the way from prescription to administration.
Automated medication dispensing carts secure medications and track dosing regardless of where the resident may be at the time.
Web-based prescribing facilitates the electronic creation and transmission of orders from desktop to pharmacy. Multi-alarm reminders and watches alert users when it's time to take medications. Multi-alarm pill boxes likewise deliver an alarm while also storing pills.
Automated crushers and splitters ease dosing by reducing pills to the appropriate size.
In barcoded medication administration, a handheld device is used to scan a barcode on the resident's wristband ID and match it against coding on the package of the medication to be dispensed.
RFID (radio frequency identification) assists with accurate medication tracking and inventory management. "[Electronic medication management tools] can be a real help if, internally, you have a good computerized system already in place-if you have electronic file maintenance and other internal systems," says Silva K.M. Gerety, corporate director of health and wellness at Brightview Senior Living.
No one would say medication management is a walk in the park. Certainly, there are potential challenges with polypharmacy, human error, and the long chain of involvement from doctor to pharmacy to nurses or assistant. Yet assisted living continues to demonstrate its ability to rise to the challenge.
"People who come to assisted living generally are getting their medication the way they are supposed to, on time, in the right dose. This is a huge benefit to our residents," Kaes says.
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