Taking the Pulse of Med Management, Clinical Execs Must Review Systems and Ensure Staff Engagement

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