Medication Management: Should It Be Skilled Care in Special Circumstances?

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Data collected on the Medicare Home Healthcare Outcome and Assessment Information Set (OASIS-C1) clearly identifies patients that may not be able to manage their medication independently at home (Centers for Medicare and Medicaid Services, 2017). Item M1100 that asks about the availability of assistance may raise a red flag if it shows only occasional or short-term assistance. Item M1700 asks about a patient's cognitive function; item M1710 asks if a patient is having chronic confusion; and item M1730 asks if a patient is showing symptoms of depression. These three items can also be indicators of potential medication mismanagement. Item M2020 discusses specifically whether a patient needs help preparing and taking oral medications safely. However, OASIS-C2 questions only focus on whether a patient or caregiver can safely fill the patient's medication box—not if they will fill the box. If it is documented in item M1100 that assistance is not, or is seldom, available, or if item M2102 indicates that a caregiver is not available or willing to assist, these are indicators that ongoing, consistent, scheduled help is likely needed for medication management. This is especially true if item M2040 shows that a patient was capable of handling their meds prior to an episode of illness or injury, because these are the patients who are convinced that they can continue independent medication management when they are no longer capable of that safely completing that task.
A common concern among physicians is patients who do not follow their treatment recommendations. According to Chesanow (2014), 50% of prescriptions are taken incorrectly, or not taken at all. Among older adult patients, the percentages are even higher—75% of elderly patients admit to not taking medications as directed, and 30% of them fail to fill new prescriptions, often due to forgetfulness, which is the most common barrier to compliance among many older adults. Not surprisingly, given these numbers, poor compliance is a serious problem, accounting for 33% to 66% of adverse events that result in hospital admissions. Poor compliance is implicated in over 125,000 deaths annually in the United States, and is estimated to cost the United States $290 billion a year in healthcare costs (Chesanow).
Medication issues significantly impact the quality of life of a large number of people in the United States, with considerable negative financial impact on society. One third of home care patients are at risk for medication errors (Mager, 2007). In addition, 3 million older adults in the United States are admitted to nursing homes due to medication-related problems, at a cost of $14 million annually (Marek & Antle, 2008). Fully 11% of hospital admissions for older adults are due to medication noncompliance, a problem that is compounded if a patient is on multiple medications. According to Meredith et al. (2001), 19% of older adults take nine or more medications with a medication error of up to 30%. As older adult patients who are discharged on more than five medications are more likely than the national average to go to the emergency department within 6 months, multiple medications also raise a red flag for older adult patients.
The purpose of this article is to examine three case studies in which patients could be kept out of the hospital or nursing home and permitted to stay at home, if medication management were considered a reimbursable Medicare nursing skill.
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