Opportunities for improving post-hospital home medication management among older adults

Effective post-hospital home medication management among older adults is a convoluted, error-prone process. Older adults, whose complex medication regimens are often changed at hospital discharge, are susceptible to medication-related problems (e.g. Adverse Drug Events or ADEs) as they resume responsibility for managing their medications at home. Human error theory frames the discussion of multi-faceted, interacting factors including care system functions, like discharge medication teaching that contribute to post-hospital ADEs. The taxonomy and causes of post-hospital ADEs and related risk factors are reviewed, as we describe in high-risk older adults a population that may benefit from targeted interventions. Potential solutions and future research possibilities highlight the importance of interdisciplinary teams, involvement of clinical pharmacists, use of transitional care models, and improved use of informational technologies.     

Opportunities for Improving Post-Hospital Home Medication Management Among Older Adults

SUMMARY

Effective post-hospital home medication management among older adults is a convoluted, error-prone process. Older adults, whose complex medication regimens are often changed at hospital discharge, are susceptible to medication-related problems (e.g., Adverse Drug Events or ADEs) as they resume responsibility for managing their medications at home. Human error theory frames the discussion of multi-faceted, interacting factors including care system functions, like discharge medication teaching that contribute to post-hospital ADEs. The taxonomy and causes of post-hospital ADEs and related risk factors are reviewed, as we describe in high-risk older adults a population that may benefit from targeted interventions. Potential solutions and future research possibilities highlight the importance of interdisciplinary teams, involvement of clinical pharmacists, use of transitional care models, and improved use of informational technologies.     

Home-medication monitoring among older adults: the breach in services

Available studies reveal alarming rates of substance and medication abuse among older adults. Professionals addressing the substance and medication abuse problems of seniors have argued for a move to medication monitoring in the home. At present, however, there has been only scattered evidence to support the contention that adequate medication monitoring actually occurs. The present study reports two surveys of all home care agencies in the state of Michigan. The first study reports the medication monitoring practices of home care staff. The second study examines possible medication monitoring interventions that might be implemented in home care agencies. Those medication monitoring interventions with the highest likelihood of successful implementation among home care staff are discussed.     

“It's a nice country but it's not mine”: Exploring the meanings attached to home,rurality and place for older lesbian,gay and bisexual adults

An ageing population across European nations, including the United Kingdom, brings with it new challenges for health and social care services and precipitates social policy initiatives targeted at meeting the care and support needs of a rapidly expanding number of older people. Ageing in place is one such policy driver—policy efforts that seek to promote the maintenance of older citizens residing in their own homes for as long as possible with minimal state intervention. Current generations of older lesbian, gay and bisexual (LGB) people have endured homophobia throughout their life histories, and sexual identity can shape perceptions and experiences of ageing, including experiences of home life, community and place. Our objective is to examine the meanings attached to home and place for older LGB adults living independently across three dimensions: rural places as “home,” connections to LGB communities, and social care provision in the home. We present interview findings from a mixed‐methods study on the social inclusion of older LGB adults in Wales. Twenty‐nine LGB‐identifying adults (50–76 years) self‐selected to participate in semistructured interviews between 2012 and 2013. Thematic findings from interviews indicate varying and contradictory meanings attached to home life in rural places, the importance of connection to communities of identity across geographical and online localities, and a high degree of ambivalence towards the prospect of receiving social care services in the home. We argue that a more nuanced understanding of the subjective meanings attached to home, rurality and community for older LGB people is needed to fully support LGB citizens to continue to live independently in their homes.     

‘Seamless care? Just a list would have helped!’ Older people and their carer’s experiences of support with medication on discharge home from hospital

Background Many older people use one or more prescribed medicines on a daily basis. Effective medicines management at hospital discharge can support appropriate use of medicines following discharge and help avoid unnecessary hospital re‐admission. Many people, however, feel they receive insufficient information about medicines on discharge from hospital. Objectives To explore older people and their family carers’ experience of hospital discharge in relationship to the organization and management of medicines. Design Qualitative interviews with older people over 75 years old, taking four or more medicines, and their carers, following discharge from hospital in the United Kingdom (UK). Participants completed medication diaries prior to the interview. Setting Interviews took place in the participant’s home. Results Nineteen interviews were conducted involving 12 carers and seven older people. Participants were generally not satisfied with the discharge process, particularly concerning perceived delays in discharge. Inadequate explanations about medicines at discharge were commonly reported and led to omission of medicines, incorrect dosage, anxiety and confusion. Poor communication between the hospital and general practitioners or community pharmacists was also evident. Conclusions Despite significant policy recommendations and research in this area, many problems with the management of medicines during hospital discharge were shown, and a lack of partnership was evident between hospital staff and patients/family carers regarding the use of medicines post‐discharge. Improved medicines management during hospital discharge is required to ensure older people take their medications as prescribed and to protect them from the adverse effects of medicines not being taken correctly.     

In-Home Medication Reviews: A Novel Approach to Improving Patient Care Through Coordination of Care

The use of multiple medications, in persons 65 years and older, has been linked to increased risk for cognitive impairment, falls, hip fractures, hospitalizations, adverse drug reactions, and mortality. The purpose of this study was to determine if trained undergraduate students, in conjunction with pharmacists, could provide in-home medication reviews and demonstrate benefit to the health and welfare of a senior population affiliated with a primary care facility. Students received training in the completion of an in-home medication inventory, assessing a home for fall risk, and performing blood pressures. Once trained and proven proficient students performed the assessments in homes of Decatur Family Medicine Residency patients 65 years and older. Collected medication inventories were reviewed by a hospital pharmacist for fall risk medications, major drug interactions, or duplicate therapy. Changes to patient management were made by the primary care provider as needed. In all, 75 students visited 118 patients in Fall 2010. Findings from the medication review include: 102 (86%) patients were prescribed at least one fall risk medication; 43% were prescribed 3 or more; 14% had the potential for a major drug interaction; and 7% were prescribed duplicate therapies. Fifty-seven patients had a subsequent change made to their clinical medication list. The results demonstrate that an in-home outreach can be successfully performed by student volunteers and provide data of high clinical relevance and use. This application of the patient-centered medical home can readily and directly improve patient safety.     

“Leaning in” and “leaning back”: Exploring the spatiality of telephone counselling

This paper explores telephone counsellors' experiences of the spatial dimensions of their work. Henri Lefebvre's spatial triad is applied to explore how counsellors conceive, perceive, and experience the spaces and places of this work. Three key findings are outlined: 1) the purpose built telephone counselling space is experienced as noisy and distracting; 2) counsellors engage in spatial practices to manage their depth of caller interaction; and 3) counsellors construct a mental place to foster intimacy with callers. These findings contribute to a novel conceptualisation of telephone counselling, raising implications for how it is performed and understood.     

Translating Research into Practice Intervention Improves Management of Acute Pain in Older Hip Fracture Patients

Objective. To test an interdisciplinary, multifaceted, translating research into practice (TRIP) intervention to (a) promote adoption, by physicians and nurses, of evidence-based (EB) acute pain management practices in hospitalized older adults, (b) decrease barriers to use of EB acute pain management practices, and (c) decrease pain intensity of older hospitalized adults.
Study Design. Experimental design with the hospital as the unit of randomization.
Study Setting. Twelve acute care hospitals in the Midwest.
Data Sources. (a) Medical records (MRs) of patients ≥65 years or older with a hip fracture admitted before and following implementation of the TRIP intervention and (b) physicians and nurses who care for those patients.
Data Collection. Data were abstracted from MRs and questions distributed to nurses and physicians.
Principal Findings. The Summative Index for Quality of Acute Pain Care (0–18 scale) was significantly higher for the experimental (10.1) than comparison group (8.4) at the end of the TRIP implementation phase. At the end of the TRIP implementation phase, patients in the experimental group had a lower mean pain intensity rating than those in the comparison group (  p <.0001).
Conclusion. The TRIP intervention improved quality of acute pain management of older adults hospitalized with a hip fracture.     

Chronic care infrastructures and the home

In this article I argue that attention to the spatial and material dimensions of chronic disease management and its place‐making effects is necessary if we are to understand the implications of the increased mobilisation – technologically or otherwise – of the home in chronic disease management. Analysing home treatment in asthma and haemophilia care, I argue that in relation to chronic disease management the home is not only always connected to the clinic but moreover, what the home is in part depends on the specificities of these attachments. Drawing primarily on the work of Susan Leigh Star and scholars of human geography I propose the concept of chronic care infrastructures designating the often inconspicuous socio‐material elements (such as medication, control visits, phone calls, doses and daily routines), which are embedded in everyday life (of both the clinic and the home) and participate in producing the effect of treatment but also the effect of home. These chronic care infrastructures demand the emplacement of various objects and activities in everyday life and thus relate to negotiations of ‘keepings’– what to keep and care for and where to grant it room vis á vis other ‘keepings’.     

Alcohol,diabetes and the student body

Type 1 diabetes is one of the most common chronic conditions of adolescence and young adulthood. It is characterized by a demanding and complex management regime. Individuals with diabetes must engage in continual self-care actions if they are to minimize their risks of developing long-term diabetes' complications. Research has demonstrated, however, that many young adults experience difficulties engaging in these types of practice, and indeed often engage in practices that are risky for their diabetes control. Narrative approaches could provide important insights into the reasons why young people engage in risky activities. In this article, the narratives of a particular group of young adults with Type 1 diabetes (university students) are examined to see what social and spatial factors underlie their risky alcohol consumption practices. This paper contributes to geographical research on risk and chronic illness, and to understandings of the interactions between bodies, spaces and risk.     

Malnutrition in the institutionalized older adult.

Most older adults in the United States live at home and are well nourished. Approximately 5% to 6% reside in nursing homes, and this segment of the older population typically suffers from multiple diseases that contribute to a high incidence of malnutrition. Forty percent of hospital beds are occupied by older persons. This article addresses the causes of malnutrition in older persons institutionalized in long-term and acute-care facilities. The causes include changes in nutrient requirements secondary to disease processes and drug modalities in combination with low or marginal dietary intake. Infections are common and result in anorexia, poor dietary intake, and malnutrition, which predispose the patient to another infection. Occurrence of decubitus ulcers is related to nutritional status and presents a serious risk for older persons with limited mobility. Depression and dementia are commonly seen in older persons and are major contributors to poor appetite and malnutrition. Cancer cachexia accounts for about half of the cases of malnutrition in older institutionalized persons. Physiologic changes that occur with age and multiple drug use place older persons at a high risk for adverse drug reactions. Less body water in the older individual influences and complicates many aspects of treatment. Standards, methods, and interpretation of nutritional assessment measurements in older persons differ from those in younger adults. The nutrition care provider must carefully consider many complex physical, medical, and psychosocial factors to deliver individualized nutrition care.     

The personal significance of home: habitus and the experience of receiving long-term home care

The physical, symbolic and experiential aspects of receiving long-term care are examined in this paper using Bourdieu's concepts of habitus and field. We draw on data from an ethnographic study of home care in 16 homes in urban, rural and remote locations in Ontario, Canada. Across all cases, data about domestic and caregiving routines were gathered through observation, interviews with clients and/or the primary family caregiver, interviews with service providers and videotaped tours of the home. Based on the analysis of these data, we argue that a transposition of logics and practices occurred when the domestic and health care fields were superimposed within the spaces of the home. Although all of the care recipients and their family caregivers indicated a strong preference for home care over institutional care, their experiences and practices within their homes were disrupted and reconfigured by the insertion of logics emanating from the healthcare field. These changes were manifested in three main themes: the politics of aesthetics; the maintenance of order and cleanliness; and transcending the limitations of the home. In each of these dimensions, it became apparent that care recipients engaged in improvisatory social practices that reflected their ambiguous and changing habitus or social location. The material spaces of their homes signified, or prompted, altered or changing social placement.     

Risk of medication errors at hospital discharge and barriers to problem resolution

Medication errors are common among older adults, particularly among those who are at heightened risk due to transfer between care settings. Determining accurate medications for hospitalized patients is a complicated process. This paper presents findings from a small pilot study conducted to identify medication documentation problems at the point of hospital discharge among older adults and the problems encountered in developing new technological systems to address these problems. A prospective study was conducted within a managed care medical center that included patient and physician surveys and chart reviews. A review of 104 medical records revealed several problems in the documentation of patient medication including legibility, use of medical abbreviations and incomplete and missing entries. While patients overall were satisfied with medications communication efforts at discharge, physicians surveyed reported that these methods were inadequate in transmitting medication lists to primary care physicians, patients and other care providers. Patients reported taking more drugs than what were listed in the medical record. These findings led to the development, testing, and implementation of an electronic medication sheet. Despite the success in developing this new system, few physicians engaged in its use, with most preferring to continue with their standard discharge practices of written communication.     

Risk of Medication Errors at Hospital Discharge and Barriers to Problem Resolution

SUMMARY

Medication errors are common among older adults, particularly among those who are at heightened risk due to transfer between care settings. Determining accurate medications for hospitalized patients is a complicated process. This paper presents findings from a small pilot study conducted to identify medication documentation problems at the point of hospital discharge among older adults and the problems encountered in developing new technological systems to address these problems. A prospective study was conducted within a managed care medical center that included patient and physician surveys and chart reviews. A review of 104 medical records revealed several problems in the documentation of patient medication including legibility, use of medical abbreviations and incomplete and missing entries. While patients overall were satisfied with medications communication efforts at discharge, physicians surveyed reported that these methods were inadequate in transmitting medication lists to primary care physicians, patients and other care providers. Patients reported taking more drugs than what were listed in the medical record. These findings led to the development, testing, and implementation of an electronic medication sheet. Despite the success in developing this new system, few physicians engaged in its use, with most preferring to continue with their standard discharge practices of written communication.     

The effects of physical environments in medical wards on medication communication processes affecting patient safety

Physical environments of clinical settings play an important role in health communication processes. Effective medication management requires seamless communication among health professionals of different disciplines. This paper explores how physical environments affect communication processes for managing medications and patient safety in acute care hospital settings. Findings highlighted the impact of environmental interruptions on communication processes about medications. In response to frequent interruptions and limited space within working environments, nurses, doctors and pharmacists developed adaptive practices in the local clinical context. Communication difficulties were associated with the ward physical layout, the controlled drug key and the medication retrieving device. Health professionals should be provided with opportunities to discuss the effects of ward environments on medication communication processes and how this impacts medication safety. Hospital administrators and architects need to consider health professionals' views and experiences when designing hospital spaces.     

Urban blue space and health and wellbeing in Hong Kong: Results from a survey of older adults

The potential benefits of aquatic environments for public health have been understudied in Asia. We investigated the relationships between blue space exposures and health outcomes among a sample of predominantly older adults in Hong Kong. Those with a view of blue space from the home were more likely to report good general health, while intentional exposure was linked to greater odds of high wellbeing. Visiting blue space regularly was more likely for those within a 10–15 min walk, and who believed visit locations had good facilities and wildlife present. Longer blue space visits, and those involving higher intensity activities, were associated with higher recalled wellbeing. Our evidence suggests that, at least for older citizens, Hong Kong's blue spaces could be an important public health resource.     

Exploring the impact of social network change: Experiences of older adults ageing in place

Social networks are sources of support and contribute to the well‐being of older adults who are ageing in place. As social networks change, especially when accompanied by health decline, older adults’ sources of support change and their well‐being is challenged. Previous studies predominantly used quantitative measures to examine how older adults’ social networks change. Alternatively, this study explores the impact of changing social networks on older adults’ lives by examining their personal experiences. We held four focus groups, two with a total of 14 older adults who are ageing in place and receiving home care and two with a total of 20 home‐care nurses from different regions and organisations in the Netherlands. Subsequently, an expert team of home‐care professionals and managers discussed and verified the results. Procedures for grounded theory building were used for analysis. We revealed four themes of high‐impact experiences: (a) struggling with illness/death of the spouse; (b) working out a changing relationship with (grand)children; (c) regretting the loss of people they have known for so long and (d) feeling dependent and stressed when helpers enter the network. Also, network dynamics were found to follow three consecutive stages: (a) awareness of social network change; (b) surprise when social network change actually occurs and (c) acceptance and adjusting to new circumstances. Together, the four themes of experiences and three stages of network change form an integrative model of the role of social network dynamics for older adults’ lives when ageing in place.     

The economic implications of self-care: the effect of lifestyle, functional adaptations, and medical self-care among a national sample of Medicare beneficiaries

OBJECTIVES: Self-care includes actions taken by individuals to promote or ensure their health, to recover from diseases or injuries, or to manage their effects. This study measured associations between self-care practices (lifestyle practices, adaptations to functional limitations, and medical self-care) and Medicare expenditures among a national sample of adults 65 years and older. METHODS: Regression models of Medicare use and expenditures were estimated by using the National Survey of Self-Care and Aging and Medicare claims for 4 years following a baseline interview. RESULTS: Lifestyle factors (swimming and walking) and functional adaptations (general home modifications) were associated with reductions in monthly Medicare expenditures over a 12-month follow-up period. Expenditure reductions were found over the 48-month follow-up period for participation in active sports, gardening, and medical self-care. Practices associated with increases in expenditures included smoking, physical exercise (possibly of a more strenuous nature), and specific home modifications. CONCLUSIONS: Certain self-care practices appear to have significant implications for Medicare expenditures and presumptively for the health status of older adults. Such practices should be encouraged among older adults as a matter of national health policy.     

Translating evidence-based physical activity interventions for frail elders

The population shift to an older America has initiated a great deal of interest in the impact of evidence-based physical activity interventions on older adults. Physical activity for older adults has tremendous benefits and is recognized as one of the most powerful health interventions for improving seniors' ability to function and remain independent in the face of active health problems and yet the majority of all older adults remain largely sedentary. To date, few programs have been developed that apply these important research findings in physical activity to frail older adults living in the community. The purpose of this article is to review past and current trends addressing increasing physical activity in the frail elderly population at home. An exemplary model of integrating an evidence-based intervention into community-based care management programs is described. Barriers encountered when implementing evidence-based physical activity interventions with frail elderly at home and recommendations for future work in this area are discussed.     

Care coordination for cognitively impaired older adults and their caregivers

Dementia and delirium, the most common causes of cognitive impairment (CI) among hospitalized older adults, are associated with higher mortality rates, increased morbidity and higher health care costs. A growing body of science suggests that these older adults and their caregivers are particularly vulnerable to systems of care that either do not recognize or meet their needs. The consequences can be devastating for these older adults and add to the burden of hospital staff and caregivers, especially during the transition from hospital to home. Unfortunately, little evidence exists to guide optimal care of this patient group. Available research findings suggest that hospitalized cognitively impaired elders may benefit from interventions aimed at improving care management of both CI and co-morbid conditions but the exact nature and intensity of interventions needed are not known. This article will explore the need for improved transitional care for this vulnerable population and their caregivers.