Why Is It So Hard to Get Detailed Medication Info from Assisted Living?

Here is a need which I’d like to see new technologies address: the need for improved and facilitated communication about medications in assisted living.

This comes up often in my clinical work and in this post I’ll share a recent true story, illustrating some of the issues. But it’s not just a problem for me; it’s an important aspect of the care of a growing aging population, which will require better integration of health care and “life care.”

Today, it’s common for people in assisted-living to be on many medications; residents of these facilities tend to have many chronic health conditions. (For an excellent overview on who’s in assisted-living and the challenges facing the industry, see Howard Gleckman’s post “The New World of Assisted Living.”)

And many of them pay to have the facility do “medication management”; this gerontology article states that this is a major reason for moving into assisted-living.

What exactly “medication management” means seems to vary a bit depending on the facility, and perhaps also on state regulations. Generally, the facility obtains medications from a pharmacy – it often seems to be one they have contracted with — and dispenses medications to the residents, based on the orders of clinicians.

Having a layer of professionals involved in medication dispensing can be pretty useful, especially when older adults have developed cognitive impairment. After all, you have someone else making sure the medications are obtained from the pharmacy, keeping medications in a safe place, and reminding patients to take them.

As a clinician, I greatly appreciate being able to know whether a patient actually took a prescribed drug. That’s because when people live independently, they often don’t take their medications as prescribed, and it can take a lot of effort to find out just what they are taking, and how often they take it. (Never mind the time and effort required to go into the reasons why they may not be taking their medications consistently, which is important and patients often have good reasons.)

So medication management in assisted-living should make this problem easier for me. But so far, it’s not all that easy for me to leverage the information that a facility has, regarding medications.

I’ve been thinking about this recently because one of my patients in assisted-living fell seriously ill recently. And it was her leaving me a message complaining about her PRN pain medication that alerted me to her significant decompensation.

Does Anyone Track Changes in PRN Medication Use?

As I’ve mentioned before in this blog, one of my top desires re medications is for it to become much easier to know how often patients are using their PRN (meaning, “take as needed”) medications.

It is a little odd that we haven’t made serious headway on this, because finding out how often a patient is using their PRN medication has obvious implications for their health, and for what we might do as clinicians:

• If a PRN medication — such as a short-acting bronchodilator for a person with COPD —  is being used a lot, then maybe the person needs more long-acting medication. Or perhaps another approach to managing the symptom/problem is indicated.
• If a PRN medication is hardly ever used, and then starts being used a lot, that would presumably signal an exacerbation or some kind of change in health status.
• If a PRN medication is used, but then the need tapers off, then perhaps the problem is resolved. This is relevant if you are treating some type of pain or discomfort, and are debating whether further evaluation and management is necessary.

Of note, it’s not uncommon for PRN medications to be controlled substances, such as Vicodin for pain, or zolpidem for sleep, or even lorazepam for either anxiety or insomnia. (Since geriatricians love to hate sedatives, I definitely want to know how often someone is taking those drugs.) Although we would ideally be informed about the use of all PRN medications, controlled substances that are especially risky for patients, or prone to diversion, are especially important to track.

Whether a PRN medication is a controlled substance or no, what are our current options for finding out how often it’s being taken?

For patients who live on their own, you have to ask patients and family caregivers for this information; the usual method is the “dig it out of their memory during the face-to-face visit” approach.  I have often asked patients to journal this, but few do. Now in principle, some of these medication management apps should be able to make this easier, but last time I tried one I found it wasn’t very easy to enter and log PRN medication use, and in general, I have yet to find a medication management app that doesn’t involve a lot of friction if you are on many meds.

Another way you can sometimes find out someone is using a lot of their PRN medication is if they ask for a refill or new prescription pretty quickly. But that’s assuming the refill request comes to the attention of the original prescriber — or of any prescriber able to think critically about the request — whereas in many practices refills are handled by the “team” and may effectively be rubber-stamped.

Now for patients who live in assisted-living, things should theoretically be easier, because if the facility is dispensing the PRN medication, then they need to log every time they dispense it. But in my own experience, it’s often been a huge pain to get this information from facilities. Patients are usually sent to the doctor with the latest medication list, not the actual “Medication Administration Record” (MAR), which records exactly what was dispensed and when.

In fact, the facility where my recently sick patient resides has repeatedly told me that they are not allowed to give me a photocopy of the MAR. Instead the med tech has volunteered to copy down the info for me.

Which is nice of her but the rule seems patently absurd. As I’m a clinician involved in the patient’s care — and the prescriber for many  of the patient’s medications, though it’s not clear that this should matter — why should there be any obstacle to my seeing a facility’s record of what they dispensed to the patient? After all, the patient has given me permission to view her health information, and has asked me to manage certain aspects of her health care.

So, as you see, if a person resides in assisted-living and a PRN medication is part of the medication management plan, then the facility staff WILL record use of the PRN medication. But so far no one is making it easy for clinicians to obtain this information on request, or as part of routine care.

An Unusual Spike in PRN Medication Use

So here’s what happened to me recently. Out of the blue, I received a message from the patient, complaining about her PRN pain medication and also about how the med techs provide it.

Now, like many of my patients, this person has some mental impairments, which means she’s not an entirely reliable reporter of things, and also means she throws in extra information that I have to figure out how to parse.

Also like many of my patients, she has a care manager involved in her care, and that person is usually the front-line in spotting problems and responding to problems. So, the patient’s message to me came out of the blue in that I hadn’t seen her for a while (because her health has been stable), I hadn’t had any concerns reported by care manager or facility staff, and also she hadn’t complained about pain or her PRN pain medications in a long long time.

Before calling the patient back, I called the facility. This patient had a long-standing order for a PRN pain medication up to twice a day, but when I’d last seen her a few months ago, a review of the MAR info — obtained after the usual wrangling — showed she’d only been requesting it very occasionally.

Now that I called and inquired, the med tech informed me that actually the patient had been requesting the medication twice a day for the past several days. Really, I asked? Well, when did that start?

I was worried that it had been going on for weeks, but actually it had started just a week prior. No slow increase in using PRN pain meds. One month, no use at all. Then suddenly, every day, twice a day. And it clearly had not been enough for the patient’s symptoms, because she’d taken the unusual step of calling me.

I called the patient, and she sounded terrible on the phone, really not like her usual self. So I called the care manager and we mobilized an urgent care visit. Ultimately, the patient was found to have pneumonia and a low blood oxygen saturation, and the urgent care clinician recommended hospitalization.

In thinking about this case, I don’t at all blame the facility staff for not notifying me of the increased PRN medication use. It’s not currently their job to detect impending illness, or to report “unusual” use of PRN medication. They aren’t trained and equipped to do this.

But given the current vogue for predictive analytics, I feel like a sudden sustained spike in PRN medication use seems pretty predictive.

More importantly, it’s indicative. It indicates a need for a clinician to check in with the patient and see what’s going on.

When will it become easier for clinicians to access medication data maintained by facilities?

Given how important medications are to the health care of their residents, and the fact that  many of these residents are at higher risk for medical complications, it seems a shame that we haven’t yet figured out a way to make it easier for clinicians to access and use the information facilities have regarding their residents’ medication use.

It is also routinely an effort to review, renew, and sometimes order medications. (I wrote a post about this over two years ago; now more facilities have computerized their med management processes but all my hassles remain.)

The problem, of course, is in large part a communication issue, with two main sub-parts. On one hand, you need viable ways to communicate useful information. You need communication infrastructure, that is secure and usable.

And on the other hand, you need people who are feeling interested in communicating. In this particular instance, the involved users are the facility residents (also known as the patients of certain clinicians), the facility staff, the clinicians who treat these residents, and then sometimes the families of the residents, who are either assisting their relative or the actual medical decision-makers.

When infrastructure for communicating is crummy, then that tends to dampen users’ motivation or interest in communicating. But nobody develops better infrastructure when people aren’t wanting to communicate. So, chicken and egg problem there.

As far as I can tell, most doctors want fairly limited medication information from facilities. They want a current medication list, when the patient walks in the door to see them. They probably also want it when they get a phone call related to the patient, but presumably they then rely on whatever’s listed in their EHR and hope it’s pretty accurate.

I get so much pushback when I ask for info on PRN medication use that I have to assume it’s not a common request of facilities.

But it should be a more common request, because it’s important if you are trying to optimize a person’s health, and health care.

What I really want these days is for all these computerized facility med management systems to offer me, an external user, the ability to easily review and request the data they have. Residents should be able to give — and withdraw — permission for specific clinicians or clinical teams to do this.

I’m busy. I shouldn’t have to spend a lot of time trying to obtain this information. Right now I have to call, or I have to fax, and sometimes I have to follow-up if the right info doesn’t come through. Sigh.

And med techs are busy. They should not have to spend time printing reports to fax to me, assuming they feel allowed to send me the information I’m requesting.

Now should I be alerted when there’s a spike in PRN pain med use? Maybe; it would really depend on how that’s operationalized. Who would set the alert criteria, and how easy would it be to set those up, or amend them? What would be the workload and legal implications? These issues would have to be sorted out, if we wanted to use PRN medication use for predictive and indicative purposes.

But in the meantime, we could still be making it easier for clinicians to obtain medication information from facilities. I hope it happens sooner, rather than later.