Coordinating resources for prospective medication risk management of older home care clients in primary care: procedure development and RCT study design for demonstrating its effectiveness

The magnitude of safety risks related to medications of the older adults has been evidenced by numerous studies [1, 2], but less is known of how to manage and prevent these risks in different health care settings. Since the 1990s, both explicit and implicit criteria have been established to decrease prescribing of potentially inappropriate medicines (PIMs) for the older adults [3‐5]. These criteria are useless unless they are implemented routinely throughout health care. Recently, the implementation has been facilitated through electronic databases, software applications and clinical decision support systems (CDSS), which have dramatically evolved over the last decade [6, 7]. The databases and CDSS systems can prospectively detect PIMs and other medication safety risks, but qualified healthcare professionals are needed to make the final decision using clinical judgement based on comprehensive patient information. Efficient use of these modern tools and skill-sets requires coordinated medication management processes in different healthcare settings.

Finland is one of the countries with advanced national health portals, databases and prospective screening systems for managing drug-related risks (Fig. 1) [8‐11]. Within less than 20 years, a wide range of medication risk management tools have been developed, with the Finnish Medical Society Duodecim playing a major role in their development [9]. These tools are widely available in Finnish health care, including community pharmacies.

Even though these innovative prospective medication risk management tools and databases are widely available in Finland, they do not form an integrated medication management process. Health care providers and units work independently, without coordination, and no one seems to have clear responsibility for identifying and solving individual patients’ drug-related problems (DRPs) [12].

The aim of this study was to integrate risk assessment tools, procedures and databases available in Finland to form a coordinated medication management model (CoMM) involving home care nurses and practical nurses (PNs), physicians and community pharmacists in the medication process of older home care clients. A study design was also developed for assessing the effectiveness of CoMM.

This study produced a 5-stage medication management procedure suitable for screening medications of a high number of home care clients and identifying clients with potential clinically significant DRPs. The model coordinates existing resources to prospective medication risk assessment providing also tools to solve identified DRPs. Nurses and PNs’ role in conducting DRP risk assessments, medication reconciliation and clinical tests during their usual home visits was clarified and reinforced. They also had a key role in implementing and following up medication changes. Triage meetings was a new and feasible way for allocating medication reviews according to clinical needs, but using a minimum of physician’s time. The coordinating pharmacist prepared triage meetings by summing up each client’s DRP risk information from different sources and making preliminary proposals for required actions for physician’s consideration. Community pharmacists’ contribution changed towards more clinical in the model. They conducted medication reviews and worked closer than before with nurses, PNs and physicians. In future, the coordinating role could be delegated to community pharmacists.

The model contains an adequate follow-up stage to confirm that the agreed medication changes will be actually implemented and the client’s health status monitored. This stage is often missing or omitted, but it is crucial for obtaining any benefits from DRP risk assessments and medication reviews [27].

The model focuses on clinically significant DRPs which may occur due to patient-related factors (e.g., age-related physiological alterations, co-morbidities, poor adherence), pharmacological effects of the medications (particularly adverse drug reactions (ADRs), high-risk medications) or the medication process of the client (e.g., poor medication management, infrequent follow-ups, various health care providers) [31]. These are the aspects that PNs were trained to observe during home visits by using the DRP-RAT tool as a guide in communication with their client or the proxy. Home visits were primarily conducted by clients’ own PNs who knew them. A clinically trained pharmacist conducted home visits only in cases in which risk assessment conducted by a PN indicated serious DRPs needing more detailed investigation. These cases were a minority in our data.

The CoMM development process revealed educational needs both in geriatric pharmacotherapy and understanding system-based medication risk management. These needs were identified in all participating health care professionals and community pharmacists. This kind of model development processes should include interprofessional training that support competence and practice development [35]. In our process, home care nursing staff and physicians had training on identifying clinically significant DRPs by using DRP-RAT and deprescribing [8, 31, 36]. Community pharmacists were identified to need training for conducting DRP risk assessments and taking more responsibility of the triage stage in the future. The coordinating pharmacist was a valuable resource in identifying educational needs and educating staff.

Our experience is that health care teams in home care benefit from having a coordinating pharmacist with qualifications in CMRs, geriatric pharmacotherapy and system-based medication risk management. Our study revealed that organizations and health care units involved in home care clients’ medication therapy are working independently in silos, nobody takes holistic responsibility for medications. The coordinating pharmacist was needed to facilitate construction of new processes and introduce new tools and approaches in medication management. She scheduled the progression of risk management stages (see Fig. 3) and regularly highlighted the primary goal of the project to those involved: the purpose being to find a feasible way to manage and prevent clinically significant DRPs of the home care clients, not to conduct scientific research. Practitioners involved were not used to working in such close collaboration, which was crucial for the model. Scarce availability of physicians’ resources and partly reluctant attitudes towards the new collaborative way of working complicated the arrangement of case-conferences of MRs and CMRs.

System based risk management perspectives through Reason’s Swiss Cheese Model [23] and Hepler and Strand’s model [24], to identify and prevent DRPs, were useful in guiding model development and constructing a shared understanding of medication safety and prospective medication risk management. Our study indicated that practitioners in Finnish health care are not well acquainted with systems thinking and this needs reinforcement in the future.

The strength in using an action research method [21] in model development lies in its ability to consider practical challenges and produce solutions, considering existing resources. The method contributed to the step by step construction of the CoMM model and description of the responsibilities of each professional involved in the model, which is missing in many other studies [27]. Transferring the model to other home care localities is possible, but will require long term effort from a qualified coordinator, committed personnel and managers to reach the mature stage of the collaboration that is necessary for sustainable changes in working patterns.

This study produced a RCT with a combination of outcome measures to assess general health status and functional ability of the older adults, but also targeted to symptoms suggestive of adverse effects of medications. DRP-RAT is used as an outcome measure to evaluate potential decreases in clinically significant DRPs. Medication lists are used to investigate changes in the quality of medications (e.g., use of PIMs). According to previous evidence, a selected study period of 2 years should be long enough to demonstrate potential changes in study participants’ health outcomes, use of health services and sustainability of changes made in their medications.

The developed CoMM procedure is feasible for screening and reviewing medications of a high number of older home care clients to identify clients with severe DRPs and provide interventions to solve them utilizing existing primary care resources. The coordinating pharmacist was needed to facilitate the construction of new processes and introduce new tools and approaches in medication management of the older home care clients.