Integrating medication risk management interventions into regular automated dose dispensing service of older home care clients – a systems approach

The study was conducted in the City of Lahti, with 119,000 residents located near the capital area of Finland. The care of older residents is mainly organized by the municipality as part of outpatient primary care, with about 1000 residents supported by homecare services (22% of all residents > 65 years old) [33]. Homecare is divided into units, each with responsible physicians and registered nurses (RNs). Each RN has a team of several practical nurses (PNs) taking care of about 25 clients.

During 2013-2015, Lahti participated in the National Interprofessional Network to Optimize Medication Use of Older Adults, coordinated by the Finnish Medicines Agency, Fimea, and financed by the Finnish Innovation Fund, Tekes [34]. The goal of the Network was to learn from feasible local practices in medication management to develop national recommendations which would optimize medications for older adults.

Lahti participated in Fimea’s Network with a local joint project between home care and hospital pharmacy. The project focused on implementing MR services and practical tools for assessing risks for clinically significant drug-related problems (DRPs). The DRP assessment tool was modified from a tool designed and validated for use by PNs to identify DRP risks in older home care clients [35]. The DRP assessment tool was combined with the Minimum Data Set (MDS) questionnaire [36]. All home care clients were assessed every 6 months for functional capacity and service needs using the Resident Assessment Instrument (RAI) [37]. RAI is a validated internationally used tool for allocating municipal home care resources for older residents [37, 38]. In Finland, RAI data is nationally collected from municipalities by the National Institute for Health and Wellbeing to make comparisons over time for policymaking [38]. The RAI assessments became mandatory in all municipalities in 2020 [39].

The research question of this study evolved when the City of Lahti decided to start using the ADD service in the home care setting in 2015. The operational implementation of the service was carried out in the spring of 2015, and the local development of the medication management process was studied by an action research method during the fall of 2015 [42]. The action research method is increasingly used in health services research [43, 44]. When applying this method, the researcher works with and for people rather than conducting research on them [42]. The development was guided by Reason’s systems-based risk management theory on preventing human errors [45] and by national policies and regulations governing geriatric outpatient care in Finland [46, 47]. Also, the best medication risk management practices of that time were benchmarked, including The Finnish Interprofessional Medication Assessment model (FIMA) for collaborative medication reviews, developed in another research project within Fimea’s Network [48].

In this study, clinical pharmacists from the Lahti Hospital Pharmacy became involved in the interprofessional home care team and their expertise was utilized in medication risk management interventions. They had an understanding of the operating processes in home care and community pharmacies, access to the electronic patient record system (EPR), and sufficient clinical pharmacy expertise based on work experience in hospital settings. Previous studies have shown that the involvement of clinically experienced pharmacists and all care team members having access to the EPR are essential for successful collaboration in medication management [31, 49, 50].

The implementation of the ADD service and related medication risk management interventions was conducted as a cyclic rotation of problem identification, preparing solutions, implementing solutions followed by evaluation and re-definition [51]. This cyclic action research process shown in Fig. 1 was led by a steering group consisting of the home care and hospital pharmacy managers. The steering group based its decisions on information gathered and summarized by two hospital pharmacists who also acted as researchers (HT, SK). Operational grass root development and piloting work was carried out by an interprofessional project team consisting of representatives of hospital pharmacists, home care physicians, RNs and PNs. Also, a pharmacist from the local community pharmacy providing the ADD dispensing service participated in the operational project team.

The researchers (HT, SK), having expertise in clinical pharmacy and medication safety, analyzed and summarized legislation and policy documents to be followed in the ADD service implementation. They facilitated the work of the interprofessional project team: 1) analyzing potential safety risks related to the local medication management process when the ADD service was implemented, and 2) by developing systemic defenses to prevent risks. The failure mode and effect analysis (FMEA) method was partially applied to identify potential safety risks and evaluate the severity of their consequences [52]. Based on this prospective risk analysis, the researchers suggested the method for local implementation of the risk management interventions (i.e., MedRec, MR and follow-ups) to be tested by the interprofessional project team before their adoption into the regular medication management process.

As the study was regarded as a development of practice, no ethics committee pre-evaluation and approval was required according to the national research ethics legislation in Finland [56]. The City of Lahti granted research permission. Good scientific practices were followed throughout the research process [57].

MedRec was conducted by a PN at the home of each home care client. The PN used a structured tool to gather all relevant information about the patient, diseases, allergies, prescription and over-the-counter (OTC) medication in use, any medication prescribed by private physicians in use, adverse effects, and other signs of possible DRPs. The tool was modified at the beginning of this study by the interprofessional project team based on the previous MedRec work in Finland [35].

The RNs used a specific RAI-screening tool to identify potential DRPs. RNs summarized the patient information gathered from MedRec, RAI assessment, and electronic patient records (EPR) using a structured documentation template. The following patient information was documented: general patient wellbeing, diagnosed diseases, drug allergies, renal and liver dysfunction, swallowing difficulties, medication self-management at home, use of self-medication products and, observed adverse effects and their duration. In addition, medication adherence was evaluated, and the medication list in the EPR was reconciled. Possible DRPs identified based on the RAI-screening, and the date of the last physician’s home visit or an interprofessional MR conducted were documented. The need for a more comprehensive medication risk assessment by a clinical pharmacist was evaluated.

RNs evaluated the patients’ information summarized in Phase 2. If no indication of a DRP was found and the medication seemed appropriate and safe, the RN and the physician worked without the pharmacist’s intervention. In cases where the possibility of DRPs was identified, the RN shared the client’s information summarized in Phase 2 with the clinical pharmacist (CP) via secure email or EPR and scheduled a collaborative meeting (case-conference). If scheduling the meeting was challenging, the CP contributed to the decision making by commenting on the clinically significant DRP findings through the EPR.

The CP conducted a more comprehensive DRP risk assessment for home care clients selected by the RN in Phase 3. The CP-conducted DRP-risk assessment covered the following aspects: clinically significant pharmacokinetic and pharmacodynamic interactions, valid indication for each drug, dose appropriateness (considering the renal function and dose recommendations for older adults), dosing times, and possible adverse effects. The risk assessment was conducted using electronic tools and databases available via the national health portal, Terveysportti, to support clinical decision-making [58]. CPs assessed the clinical significance of the identified DRPs by using the RN’s patient information documentation (i.e., summary formed in Phase 2), and other relevant patient information available in the EPR, such as laboratory test results.

The MR was conducted during an interprofessional care team meeting (case conference) initiated by the RN. The RN shared with other care team members a summary of the patient information formed in Phase 2, and the CP shared a summary of the findings of the DRP-risk assessment conducted in Phase 4. An outcome of the case conference was a summary of the client’s medication status, and a decision on required actions to solve the identified clinically significant DRPs. The physician made decisions on the medication regimen, confirmed the client’s medication list, instructed medication therapy implementation and follow-ups, and decided whether the client’s medication was suitable for ADD dispensing.

The aim of the case conference was not only to review the medication to identify adverse effects and interactions. It also covered discussion and decision on the need for follow-ups to monitor attaining treatment targets and self-managing the medication at home. Based on the case conference, a comprehensive medication therapy plan was formed and documented into the EPR. In some cases, the physician and the RN had to meet the client for a more comprehensive clinical examination before the medication therapy plan could be confirmed.

After the case conference meeting, the RN guided the PN to implement the changes, administer and document daily medicine taking, and follow up the medication therapy at the client’s home. In routine practice, collaborative MRs were planned to be conducted once a year for each home care client to ensure appropriate prescribing for each of them [47]. It was also locally agreed that a collaborative MR will be conducted more often in the event of suspected clinically significant DRPs.

The implementation of the ADD service changed work processes, particularly, medication ordering and dispensing phases. Therefore, they were considered high-risk phases (Fig. 3). The ADD medication orders were scheduled, and practices were set up for unusual ordering schedules, such as acute stopping and restarting the ADD service due to inpatient care periods. The medicines that were not suitable for the ADD service but were manually dispensed were mainly high-risk medications, such as insulin and anticoagulation therapy. A combined medication list, covering both dose-dispensed and manually dispensed medicines, was introduced to guide the PNs work and prevent errors in the medication ordering and dispensing phase (Fig. 3).

Medication administration and follow-up were documented in the EPR. Clients were responsible for taking their medication, if their abilities and condition allowed it. However, PNs were responsible for the medication administration for most of the home care clients. PNs were also responsible for medication follow-ups and counseling. These phases were identified as high risk because of the significant changes made compared to previous practices (1st and 2nd model in Table 1). The most significant change was that PNs’ responsibility extended to conducting medication follow-ups and documenting observed findings of the effects of the treatment using a structured form in the EPR. These were new phases that required collaboration between RNs and PNs. The risk of forgetting to administer both the ADD dispensed and manually dispensed medication (mainly high-risk medications) was also deemed to be high. A combined medication list that was introduced supported preventing these errors (Fig. 3). The new phases and tasks were instructed in detail for the nursing staff. Special attention was paid to introducing them to the new systemic defenses for the identified preventable medication risks (Fig. 3). The role of the community pharmacy providing the ADD service was to organize regular on-site group training for the home care personnel on any timely medication safety-related topic they needed to know, such as the safe and rational use of high-risk medications. The training also supported PNs in counseling their clients on medication. In addition, on weekdays, the community pharmacists were responsible for answering any medication-related questions that the home care personnel had.

A client’s medication regimen and the implementation of any medication changes were evaluated in meetings between physicians and RNs, utilizing the documentation available in the EPR. The comprehensive medication therapy plan was updated and confirmed if this was deemed to be necessary. The RN represented the client as in the previous phases of the process.

As a result of the study, the division of health professionals’ responsibilities became more explicitly defined, leading to more effective use of available resources in the medication management in home care (Table 1; Fig. 2: 3rd model). The PNs’ role evolved to focus on medication follow-ups and more standardized documentation instead of only manually dose dispensing and administering medicines. The PNs also became more involved in medication counseling. The tasks between RNs and CPs became more explicitly defined and changed to avoid duplicate work in collecting and summarizing patient information for medication reviews in the 3rd model compared to the 1st baseline and the 2nd model (Table 1).

Tools for the MedRec and medication follow-up were established. These guide the PNs’ work and more structured patient information documentation into the EPR. Respectively, a specific RAI-DRP-screening tool and structured documentation strategy into the EPR improved collaboration between care team members. Based on the systematic work of the PNs and RNs, the CPs’ time was allocated to the selected home care clients at potential risk for clinically significant DRPs. The medication review phase (Phase 5) evolved from the teamwork between the physician and the RN at baseline (1st model) to a collaborative teamwork involving also a CP in the 3rd model (Table 1). Based on the preparatory work of the RN in Phases 2 and 3 and the CP in Phase 4 and its structured documentation, the goal of the interprofessional case conferences evolved to establishing comprehensive medication therapy plans for individual home care clients. The explicit therapeutic goals and tasks for each care team member involved in implementing the medication therapy plan were mutually agreed during the case conference.

As a result of the study, the local procedure for starting the ADD service and implementing changes to ADD customer’s medication regimen was defined. It was also recognized that the medication regimen of clients with the ADD-dispensed medicines should always be up-to-date. This avoids the need for a PN to open the medication sachets for additions or removals of medicines which can contribute to dispensing errors. Therefore, the ADD sachets’ order and delivery were synchronized to be compatible with the home care weekly routines, and the timing of the case conference on the clients’ medication regimens. The role of community pharmacists focused on managing medication orders, dispensing, and delivery processes, and answering daily medication-related questions from RNs and PNs (Table 1). In addition, community pharmacists became responsible for regular on-site training for home care personnel.

In this study, the development work of the interprofessional project team was supported by the steering group consisting of the supervisors and managers (Fig. 1). This organization strengthened the adoption of the new, standardized medication risk management process and facilitated problem-solving in the implementation project. For example, in some cases, a MR was conducted, but the physician’s timely clinical decision about the medication changes was missing, leading to outdated and unusable MR information. Some challenges were also encountered in implementing the planned medication changes, especially in cases where several changes needed to take place in stages. Also, the CP who was working only a few days a week in home care posed some additional scheduling problems to the project. The challenges were discussed in the steering group meetings and changes to improve overall scheduling were agreed. A separate form was introduced to support phased implementation of the medication changes and follow up of tasks agreed in the case conference.

To quantify the benefits of the implemented ADD service and related medication risk management interventions, an informal questionnaire was sent to the home care personnel having experiences of the newly implemented practice. According to the results, all the home care respondents reported benefitting from the new medication management process with evolved interprofessional collaboration. Systematic preparatory work of the PNs, RNs, and CPs in Phases 1-4 improved quality of the medication follow-up data and facilitated decision making in the collaborative case conferences. The medication risk management interventions, tools and collaboration was reported to improve the RNs’ and PNs’ geriatric medication knowledge, as well as RNs’ ability to evaluate the status of clients’ medication management as a whole. The collaborative approach improved the efficacy of the clinical pharmacists’ work and deepened their clinical pharmacy expertise.