Recently I’ve been trying to more intensively adjust medications for a few patients who live in assisted-living facilities.
Intensively, meaning that I might change the medication every 1-2 weeks, as the patient and I engage in a focused effort to figure out how best to manage a certain problem, such as pain, anxiety, insomnia, constipation, or falls.
Sometimes, I even have to change the medication after a day or two, if the most recent change seems to have made things worse instead of better.
All of this means lots of communication with the facility, the medication technicians, and the pharmacy. (And with the patient, but that’s often the easiest part.)
It has, for the most part, been a bit labor-intensive and challenging, especially when it comes to those facilities that use paper-based medication administration records (MARs). Hence, I’ve found myself thinking about how clinicians and facilities can coordinate and communicate regarding medications, in order to improve the care of patients.
The nice thing about having patients in assisted-living is that many of them use the facility’s medication management service, which means they will be reminded to take scheduled medication, and there will be a record of what has been taken. (For those elderly adults who live at home, figuring out what they take and how often can be quite a challenge.)
On the other hand, the facility’s involvement means there is an extra party involved in the communications. So as a clinician, you can’t just tell a patient to stop a medication. You also have to write an order for the facility.
Also, in most cases, if you prescribe a medication PRN (“as needed”), the patient will need to go ask the facility staff in order to get it. Many patients experience this as a barrier to access, and complain that they don’t get PRNs easily from their facility…it seems that they either are uncomfortable asking, or the med techs are hard to find, or something else seems to come up. Of course, the clinician may be able to authorize that the patient keep the PRN medication in his or her room, and self-administer. But in this case, it can be hard to determine just how much PRN medication the patient has taken.
To summarize, the main hitches I’ve run into are:
- More effort required to prescribe medications or make changes, since the facility may require orders separate from the pharmacy prescription.
- Orders and prescriptions usually have to be sent by fax.
- Clarifications and questions are often sent back to me by fax.
- Follow-up phone calls are often involved: either I call to make sure they got an order and have no questions, or they call me because they need more information.
- Effort required to get a copy of the updated medication list, in order to make sure that all changes have been implemented correctly.
- A copy of the most up-to-date medication list is also important if the patient is seeing other clinicians or specialists, who may have added or changed medications.
- I usually have to call to request this information; faxing sometimes works but takes longer to get a response and sometimes there is no response. I also sometimes have to walk over to the facility’s med room, to get a copy of the list.
- Extra effort often required to get a record of how often PRN medications were administered.
- Some facilities chart this by hand, separately from a pharmacy-generated list of current prescriptions.
- This information is often not included when a medication list is faxed to me.
- Patients and families are often concerned that they won’t be able to get PRN medication promptly when it’s needed.
- Cognitively impaired patients may have difficulty asking or recognizing their own need for medication.
- Some patients complain that facility staff are slow to respond to PRN requests; I suspect that this is because the med techs tend to be very busy dispensing a lot of medications, and possibly also transcribing the latest changes to the orders.
What would help
- Providers and families would be able to view the facility’s current medication orders in real-time.
- Providers would be able to easily make changes, and it would only require one step to notify all parties of any change.
- Changes should be made electronically, and no one would be copying prescriptions or orders into a binder.
- Providers would easily see how often PRN medications had been administered. Families may also want to view this information, in order to participate more fully in the plan for managing a certain symptoms or problem.
- Providers could easily copy or import the latest medication list, and PRN medication use, into their own electronic health records.
- Families and patients may want to import this data into their own personal health records as well.
- Patients and families would be easily able to give other providers access to this data.
But it’s a long road from good idea to actual implemented solution with good usability. To begin with, it’s quite hard to design a comprehensive solution that works well for all parties involved. Then, there’s the challenge of getting providers and facilities and pharmacies to all use a single system. (Alternatively, we can each use our own system but then we need the systems to talk to each other easily…easy to wish for, hard to achieve.)
Just as physicians’ offices are slowly but surely moving from paper to electronic record-keeping, I’m sure that eventually all assisted-living facilities will have fully computerized medication management, along with electronic systems of care coordination and clinical communication. But how many different platforms will providers be willing to work with?
Many providers are already struggling with an EHR in clinic, and possibly another one for the hospital system they might be affiliated with. In such circumstances, providers might well balk at using a facility’s communication platform as well, and instead insist on continuing with the current system of faxing in orders. (Most providers, as best I can tell, don’t feel compelled to double-check the medication list as often as I tend to, so my problems are not quite their problems.)
As usual, we are left with some thorny issues to resolve as we work our way towards better communication and coordination.
For now, I am still waiting to be invited to a facility’s communication platform, and am hoping that a nearby facility tries something like Caremerge soon. (I’ve listed a few other issues I try to coordinate with assisted living facilities in this post.)
If you’re a clinician and have had any experience with a care coordination platform in assisted-living, I’d love to hear your thoughts on it.