assisted-living

How many phone calls & faxes does it take to evaluate a common complaint in assisted living?

February 12, 2016

If we are going to provide compassionate and effective care to an aging population, at a cost we can all afford, we are going to have to get better at dealing with health concerns that come up often.

I am perpetually struck by how much effort and friction is involved, when I have to address certain common health issues.

Today I’m going to share a recent example: new confusion in a 90-year-old elderly woman who lives in assisted-living. Goals of medical care are to avoid hospitalization, and to focus on optimizing function and comfort.

Brief backstory: this elderly woman has Parkinson’s disease, but generally has very good cognition. She has private 24-hour caregivers because she can’t get up out of chairs on her own, needs stand-by supervision when she gets around her apartment with a walker, and needs to be taken by wheelchair to the dining hall and other locations within the facility. She also needs help with continence care. And, she’s been getting home health services for the past few months, for a sacral pressure sore.

As you can see, lots of people involved in her health and care: private home aides, home health agency RN, assisted-living facility staff (which includes their own RN), and an attentive adult child who visits often. This lady is essentially home-bound but very occasionally gets out to see her neurologist or another healthcare provider.

And now for what happened with confusion. For me the story started when the woman’s son sent me a message, saying his mother was now having delusions and crazy thoughts, and that her paid caregiver said she hasn’t been herself for the past 36 hours.

So this sounds like delirium: worse than usual mental functioning, generally brought on by an illness, stress on the body, or sometimes by a medication side-effect.

In other words, this is a common concern that comes up for many older adults, especially if they have a chronic condition that can cause cognitive impairment, such as Parkinson’s.

And cognitive impairment is apparently very common among assisted-living residents. Here’s what a 2014 Health Affairs paper says:

Estimates derived from national data indicate that seven out of ten residents in these residences have some form of cognitive impairment, with 29 percent having mild impairment, 23 percent moderate impairment, and 19 percent severe impairment. More than one-third of residents display behavioral symptoms, and of these, 57 percent have a medication prescribed for their symptoms. Only a minority of cognitively impaired residents reside in a dementia special care unit, where admission and discharge policies are more supportive of their needs.

Given this data, delirium must be very common in assisted-living, and you’d hope that a clinician would be able to evaluate and manage without too much hassle. But let’s see what happened in my case.

Evaluating a worsened confusion complaint in the real world

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

November 20, 2015

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?

Wanted: A managed personal health record for assisted living

October 10, 2013

[The following clinician guest post is by Dr. Alan Pitt, who is helping to plan a senior living community under development. We met recently at Health 2.0, and he was nice enough to write a post about the tech tool he is currently looking for: a managed personal health record. (This post is cross-posted to his blog too.) Thanks Alan!]

“I’m not as scared of dying as I am of growing old.” – Ben Harper, Glory and Consequence

Whether we admit it or not, most of us are afraid of growing old. There is a sense of loss, of youth and vigor, coupled with the burden of managing your health in relative isolation. Although Americans would like to think that we are each responsible for our own care, most of us as individuals would far prefer for someone to be there, helping us through our time of need. Years ago I was advising one of the Presidential hopefuls regarding a healthcare platform. I suggested that the position should be that individuals be responsible for their own health, but as a country we would partner to provide the tools for the individual to succeed. Now, almost a decade later, we are not much closer to this goal.

Personal Health Records (PHRs) were thought to be the answer. These records differ from more traditional EMR in that they are owned by the patient and aggregate information from multiple sources to give a complete picture of the patient. For example, they might include clinic visits from multiple providers, hospitalizations and updates on an exercise program. Literally billions were spent on PHRs by the likes of Microsoft (HealthVault) and Google. Both efforts were failures with thousands (in the single digits) rather than millions of enrollees. As noted by David Shaywitz, healthcare is a negative good, something viewed more with resentment than in any way positive. And that extends to things that keep us healthy. To interact with your health means you are imperfect, you are mortal.

Rather than a PHR, I would like to propose a different tool, a managed PHR (mPHR). This would be owned by the patient, but managed by a surrogate, such as a family caregiver or even a care coordinator (CC). This person would be responsible to keep the person on track, taking their medications, keeping their appointments, explaining their illness (or at least researching their problem). This may seem far fetched, but I believe CC will be a new job in 3-5 years. And when this army spreads across the land, they’ll look for a tool to do their work. And it won’t be an EMR. It will be a mPHR.

What would the perfect mPHR do?

Here is a list I’ve compiled:

Collect and organize data from disparate hospitals and clinics
Store and view previous radiology exams
Facilitate med reconciliation and education
Send reminders
Manage exercise programs
Allow differing levels of permissions and access…for the patient, the advocate and family
Message those defined in the persons ecosystem if the PHR identifies a down trend.
Report on utilization and changes in utilization
Collect biometrics such as weight and blood pressure, and also track problems such as depression and pain indices with reporting and messaging
Link/suggest support groups based on the problem list
Leverage secure texting and email for messaging
Be platform agnostic & cloud based

The critical thing here is actually not the functional requirements…these have already been fairly well defined…it is the ability to easily work with surrogates and family while maintaining some level of choice and control by the patient.

This is not an idle ask. I am now working with a developer building senior communities with integrated care and care coordination. I can buy an EMR, but not an effective PHR for these communities. With any luck at all, we will be managing thousands of lives in these communities in the next few years.

To all you bright entrepreneurs out there, help me out. Build the perfect mPHR. If I am right, and there is a lot of evidence I am, you’ll transform how we care for one another, and make a lot of money doing it. I won’t be your only customer.

Alan Pitt, MD, is a Professor of Neuroradiology at the Barrow Neurological Institute in Phoenix, AZ, and has been a speaker at Health 2.0. His skills and talents include cloud-based informatics, innovations in telehealth, and finding financially sustainable ways to improve healthcare. You can reach him at alanpitt [AT] me [DOT] com.

Medication coordination & assisted living

August 2, 2013

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

For many of the issues listed above, a solution would be an electronic communication platform that included the providers, the pharmacy, the facility staff, as well as the patient and family.

Ideally:

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.

Health innovation to the rescue! Some companies are working on just this kind of solution. (I mentioned one of them, Caremerge, in a post last fall.)

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.

What clinicians need to coordinate with assisted living facilities

May 21, 2013

How could, or how should, clinicians coordinate health care with assisted living facilities?

This is the question I was asked recently, by someone working with a senior living developer. Like many, the developer is hoping to leverage technology for better care coordination, care collaboration, and overall better aging-in-place.

It’s an appealing idea, and we certainly need better coordination of care and information for seniors. But it’s a tough problem to solve, especially when people are residing in facilities.

For instance, as I wrote last fall, I once found myself sending faxes to the PCP, the neurologist, the home healthcare agency, the private in-home caregiving agency, and to the facility itself. Plus I was emailing the patient’s family on the side. And we didn’t even have the hospital transition team involved; although that case was related to an elder doing poorly after hospitalization, by then the patient was well outside the 30 day window of interest to hospitals.

How can clinicians and assisted living facilities coordinate on healthcare for older adults? Sorry, I can’t answer that question yet.

However, what I can do is specify some of the issues that I find myself trying to coordinate with assisted living facilities.

Coordinating medications with an assisted living facility

This probably constitutes the bulk of how most clinicians interface with assisted living facilties. Here are some of the communication issues that often come up in my practice:

Requesting a copy of the current medication list, so I can see what may have been prescribed by other providers. Ideally a current medication list would be viewed by clinicians every time a complaint is assessed, or medications are prescribed. In reality however, clinicians often end up relying on outdated/incomplete lists.

Discontinuing medications. When patients are having medications dispensed by assisted living, it’s generally not enough to just tell the patient during a visit that they should stop something. Clinicians also need to send an order to the facility. It would, of course, be nice if there were an easy way to double check that a medication had been discontinued as requested (currently requires more phone calls and faxes).

Ordering PRN (“as needed”) medications. Ordering is actually the easy part. The hard part is figuring out how patients will voice their need, and making sure that the facility is able to respond. Most of the time, patients and families tell me that they have difficulty getting PRN meds dispensed by facility staff. My guess is that this is because the facility staff are relatively busy, and perhaps haven’t had much training in managing PRN meds.

Requesting a log of how much PRN medication was given. This information is essential if a clinician is to properly adjust a medication regimen and manage symptoms appropriately.

However, I’ve found is often absurdly difficult to get this data, and facility staff are usually puzzled when I ask for it. In fact, the staff at one facility recently told me that their policies forbade them from giving me a copy of the MAR (“medication administration record”), which is the part of the medication chart where staff document when they actually give medications. (Weirdly, the med tech offered to hand write the information for me; I pointed out that this was error-prone and insisted on talking to the nursing director about the policy.)

Clarification/confirmation of current orders. Facilities often contact me if they have questions about a new medication order. Many facilities also fax a medication list regularly and ask the primary care doctor to confirm that the med list is correct. (Which can be challenging if the patient has been seeing lots of other doctors.)

Other issues I coordinate with assisted living facilities

Other than medications, I also sometimes try to coordinate regarding:

Monitoring of blood pressure. Most facilities won’t check blood pressure every day indefinitely, but they can often manage a few checks over a week or two. I’ve found I often have to remind them to send me the data however. (Same goes for the home health nurses; they are easy to reach by phone and delightful to talk to, however they don’t always send me the information I ask for. Presumably it’s not well within their workflow to send specific info to doctors, whereas sending the [nearly useless] mandated reports IS in the workflow.)

Obtaining information regarding the person’s cognitive and physical status. I often want to know how a person has been doing cognitively and physically. Are their mental abilities same as usual, or worse? What kinds of activities of daily living do they need help with, and any recent changes? How far are they walking, and with what kind of assistive device? Facility staff are excellent people to query on this topic, if you can get the right person on the phone.

Responding to facility concerns regarding health or behavior. In my experience, facilities usually send a fax when there is an event or change that they are concerned about. (Occasionally they call, but not usually.) I then try to call or fax back, in order to get more information so I can address the concern. The back-and-forth can be time-consuming.

Behavioral interventions. This one is very tricky, especially when it comes to patients who are cognitively impaired. Many older patients can benefit from changing their own actions (i.e. timed toileting for incontinence, or a daily short walk to maintain mobility), but they need assistance or reminders to do so. Some facilities are able to provide this kind of behavioral support; others aren’t.

Summing it up

In my own work as primary care doctor and geriatrician consultant for the elderly, I’ve found that most of my communication with assisted living facilities centers around medication management issues. I also often communicate regarding short-term monitoring and to try to get information about the patient’s cognitive and physical function.

Obviously, there are plenty of opportunities for technology to facilitate communication and collaboration regarding the above issues. But it’s also quite challenging to develop something that all the involved parties can and will use.

Clinicians and others, if you’ve come across technological solutions that work well for the needs listed above, please let me know or post in the comments.