Clinical Note Expanding Clinical and Information Services to the Ambulatory Older Adult Through Community Outreach Programs Paula Evans, Timothy Dy Aungst, Colleen Massey, Donna Bartlett Objective: To share successful techniques pharmacists can
use to educate community-based older adults about health and medications. Setting: Events coordinated through MCPHS University Pharmacy Outreach Program and offered at Massachusetts senior centers. Practice Description: The MCPHS University Pharmacy Outreach Program, staffed with pharmacists, caseworkers, and pharmacy students, under the supervision of licensed pharmacists, provides free medication-related information to Massachusetts residents. Clients also receive assistance with cost-minimizing programs and insurance benefits. Seventy percent of contacts are older adults. Services are provided through a toll-free number and outreach programs. Practice Innovation: Focus on expanding educational health services and includes selecting Medicare D plans, working with support groups, providing medication management for diverse cultures, educating older adults on how to search for health information on the Internet, and discussing medication safety and adherence. Main Outcome Measurements: Participant and pharmacy student knowledge assessed utilizing survey tools. Additional measurements include savings for Medicare beneficiaries and improvements in medication management. Results: Observed results of the Pharmacy Outreach Program include decreased out-of-pocket costs for Medicare beneficiaries, improved medication adherence resulting in reduction of glycated hemoglobin and blood pressure, identifying and recommending medication treatment changes to reduce patient fall risk, and increased confidence in locating Web-based health information. Pharmacy students
demonstrated increased knowledge of and ability to communicate Medicare benefits. Conclusion: Outreach programs can improve older adults’ understanding about their health and medications. Pharmacists can increase visibility in the community by engaging in effective outreach programs. Key Words: Adherence, Community outreach, Cultural diversity, Falls, Medicare Part D, Medication therapy management, Older adult, Pharmacist, Pharmacy outreach program, Senior center, Student. Abbreviations: AD = Alzheimer’s disease, HbA1c = Glycated hemoglobin, OOP = Out-of-pocket, PD = Parkinson’s disease, PIM = Potentially inappropriate medications. Consult Pharm 2015;30:31-7.
Introduction Older adults are often encumbered with several comorbidities that require multiple medications. They can also be presented with complex daily drug regimens and potential side effects that may reduce their overall quality of life and lead to adverse outcomes.1 Additionally, out-of-pocket (OOP) costs of these medications may pose a financial burden, potentially decreasing their access to necessary treatment.2 Faced with multiple medications, side effects, and costs, some older adults find it difficult to take their medications as prescribed, and adherence becomes problematic.3,4 Pharmacists are well-positioned to address these issues given their clinical skills and exposure to high medication costs. Community outreach programs allow pharmacists to engage directly with older adults and address some of these concerns. Programs and services provided by pharmacists can improve upon the older adult’s knowledge of diseases and drugs and subsequently reinforce adherence. These programs put the pharmacist in an ideal position to help older adults overcome some of the barriers they face in taking care of their health.2,4 Pharmacists from community, hospital, and academic settings can coordinate with community organizations, such as senior centers, that serve this population. The MCPHS University Pharmacy
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Clinical Note Outreach Program works with multiple senior centers and state-funded programs in Massachusetts to help address pharmaceutical issues of older adults in the community.5,6 Effective programs are defined for pharmacists looking to engage with a community-based older adult population about their health and medications. The aim of this paper is to share successful techniques pharmacists can use to educate community-based older adults about health and medications.
Practice Experience The MCPHS University School of Pharmacy Worcester/ Manchester operates a full-time Pharmacy Outreach Program where pharmacist faculty and case managers provide free medication-related educational services to the general public and health care practitioners in Massachusetts. This program was established in 2001 and is funded with a nonresearch service grant from the Commonwealth of Massachusetts, Executive Office of Elder Affairs, and several other community programming grants including existing contracts with Central Massachusetts Agency on Aging and the City of Boston. Funding is also obtained from local agencies, such as visiting nurse associations, on a per-patient consultation basis. It was among the first programs in the nation to address the need for assistance at a statewide level. While the program helps individuals of all ages, 70% of the clients served are older adults. Clients can access medication information and receive assistance with cost-related programs and insurance benefits through a toll-free number, the Internet, or outreach programs. Through the toll-free number, callers gain access to a team of pharmacists and case managers at the information call center who help them with insurance options, specialized outreach agencies, and assistance through pharmaceutical manufacturers. In addition, clinical pharmacists conduct medication reviews and provide counseling and compliance monitoring. Through the Pharmacy Outreach Program Web site, residents of Massachusetts are able to reach a pharmacist using the convenience of the Internet.7 “Ask the Pharmacist,” an e-mail link from the outreach program’s
32
Web site, allows pharmacists to respond to client information requests. In addition to the services offered through the helpline and the Internet, the program provides an array of educational programming throughout Massachusetts through other outreach programs that are created to fit the needs of patients, providers, and the overall community (Table 1). Some of the innovative programs and techniques used to reinforce the health message are detailed below and may offer an insight into programs or parts of programs that other pharmacists practicing in the community may be able to use. Additionally, consultant or other community pharmacists may have an opportunity to meet with other agencies and build expanded contacts when engaging in outreach programs. Working jointly with faculty members at a school of pharmacy or with pharmacy students may ease some of the time commitment and provide a wider range of services.
Outreach Programs Medication Safety and Medication Management Older adults in the community may be at risk for adverse events from their medications. Several drug criteria and tools (e.g., the Beers criteria, START/STOPP criteria) help identify potentially inappropriate medications (PIMs) with this population.8,9 Many of these PIMs are responsible for drug-related admissions to emergency departments.10 Pharmacists are in a prime position to help identify and educate individuals in the community on PIMs and general medication-related safety.11,12 Medication safety for the older adult is an important teaching point for the Pharmacy Outreach Program. Sessions at senior centers begin with a viewing of an inhouse-developed DVD highlighting safety concerning the correct way to take, store, and dispose of medications. Auxiliary labels are reviewed to help audience members understand how best to adhere to these special instructions. Following viewing of the DVD, there is a group discussion, then one-on-one medication counseling, including simplification of daily regimen and proper medication timing. The adults are told about key side effects
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Expanding Clinical Information for Older Adults In the Community
Table 1. Outreach Programs Offered by the MCPHS University Pharmacy Outreach Program Service
Type
Medication Safety
DVD, Presentation
Medication Management
DVD, Presentation
“Ask the Pharmacist”
Consultation
Senior Center Health Fairs
Informational
Fall Prevention
Presentation
Medicare Education
Presentation
Medicare Part D Evaluations
Consultation
MedlinePlus
Learning Series
MTM for Diverse Cultures
Consultation
Health Condition or Disease-Specific Education
Presentation
• Low-Vision Support Groups • Parkinson’s and Alzheimer’s Disease MTM
Consultation
Abbreviation: MTM = Medication therapy management.
and educated on what to do should they occur. A second DVD has been developed concentrating on medication management and medication adherence. In this DVD, pill organization, understanding the need of medication therapy, and incorporating medications as a part of a daily routine are addressed. These short, 8-to-12-minute DVDs focus the audience and allow for interesting question and review. Patient knowledge is assessed through the use of postprogram surveys. The data indicate that the programming has a highly positive impact on the patients’ understanding of their medications, safety, and adherence.
Education on Fall Prevention Preventing falls is an important subject for pharmacists to discuss with older adults and various health care providers. Specific programs have been developed targeting each audience. During community presentations, older adults are taught that falls are multifactorial and that some
medications may increase their risk. Medications are evaluated and suggestions made for better, safer alternatives. The Pharmacy Outreach Program also provides continuing education sessions for health professionals, including nurses and physical therapists, to raise awareness of medications that may increase fall risk and introduce criteria to help assess the medications of their patients.10,11 These educational sessions often prompt the attendees to recommend a pharmacist review the medication profile for potential interventions. Finally, the Pharmacy Outreach Program consults for several organizations in the region through contracts on a patient-fee basis. Pharmacists are part of a fall-risk reduction program for recently hospitalized patients discharged into a visiting nurse association service, and review patient profiles for PIMs.13 This is accomplished through remote access to electronic health records. Pharmacists’ recommendations are documented in the visiting nurse records and can then be viewed by connecting health care
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Clinical Note personnel. Pharmacists reviewed records of 100 patients (65% female, mean age 84 ± 6 standard deviation), assessing the types and number of medication interventions and clarifying dosing and durations of treatment. Interventions included appropriateness of proton-pump inhibitor use (32%), medication treatment suggestions (20%), and vitamin D/calcium suggestions (16%).13 Clinical pharmacists, as part of a visiting nurse association service, can identify medication-related problems through remote access to patients’ electronic medical records and help prevent possible adverse outcomes.
Cultural Group Services at Senior Centers Senior centers provide opportunities for older adults of different cultural backgrounds to gather. Within the service area of the Pharmacy Outreach Program, there are weekly social networking and activity programs for the Vietnamese, Chinese, Iraqi, Latino, and Portuguese cultural groups. The pharmacy program is promoted by connecting with a staff member at the senior center who coordinates services for the group, announcing all pharmacy services with a poster in the native language, offering educational programs to the group first and individual medication reviews second, using students or providers who speak the native language and know the culture and habits. This model was followed working with 50 nonEnglish-speaking older adults of Vietnamese ethnicity.14 Educational presentations were offered on adherence, healthy food substitution in Asian diets, and supplements and medications in diabetes and hypertension. Medication reviews were completed for all participants, and personal medication charts were compiled and transcribed into Vietnamese. Preliminary survey data suggest participants strongly agree that the information provided improves understanding of diseases, medications, and the importance of adherence.14 In another series of programs focusing on non-English-speaking older adults (Hispanic), pharmacist-led medication management was beneficial in improving health outcomes by providing continuity of care between physician visits.15 Monthly screening and education over a four-month period assessed changes in blood pressure and glycated hemoglobin (HbA1c) as a result of management of chronic conditions. Participants
34
experienced lowering of blood pressure and HbA1c after four months.15
Social Support Groups at Senior Centers Senior centers provide opportunities for health-related social support groups to gather. The Pharmacy Outreach Program has discussed issues pertaining to low vision, Parkinson’s disease (PD), and Alzheimer’s disease (AD), and communities can connect with other support groups. These are interactive, friendly gatherings that often include patients and supporting family and friends. They usually meet monthly and look for speakers who can offer assistance and education on health-related topics. For the low-vision population, pharmacy students, under the supervision of licensed pharmacists from the Pharmacy Outreach Program, discuss how to organize and take medications safely when dealing with challenges associated with macular degeneration, glaucoma, and cataracts. PD groups have requested help with proper medication timing and how to best afford medications with certain Medicare D prescription insurance plans. AD groups are interested in alternative and natural products that may help with the disease process. Additionally, brown bag reviews are encouraged at all programs. Pharmacists serve as mediators for questions and discussion among group members while providing appropriate and reliable information. Medicare Training and Patient Plan Evaluation The Medicare Part D benefit design is complicated and often confusing for many older adults, and the system leads many to select inappropriate plans.16 Plans change from year to year, and beneficiaries in Massachusetts often have more than 30 stand-alone Part D plans from which to choose.17 Each private Part D plan sponsor can make changes to the plan’s cost-sharing structure (monthly premium, deductible, coinsurance) and formulary, including utilization and cost-control mechanisms (step therapy, prior authorization, and quantity limit). Many older adults benefit from educational sessions that help them understand the impact of the yearly changes.18 To address the need for clear, comprehensive, and up-to-date information, Pharmacy Outreach Program presentations are held throughout the state in the fall of each year.
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These sessions focus on educating older adults on the benefit design, eligibility and enrollment guidelines, additional assistance options, and changes to expect in the upcoming benefit year. Beneficiaries may unknowingly qualify for additional secondary assistance to help cover the costs of Medicare Part D and require guidance with signing up for these programs. These programs include a federal assistance program through the Social Security Administration called “Extra Help” or a state pharmaceutical assistance program such as Prescription Advantage in Massachusetts.19-21 Additionally, Medicare Part D openenrollment events are held each fall to offer beneficiaries an opportunity to evaluate their plan options with trained pharmacists, pharmacy students, and case managers. OOP expenses are a barrier to medication access for older adults covered by Part D, resulting in poor adherence and disease outcomes.22 Pharmacists have previously proven the viability of performing Part D yearly reviews and reducing OOP expenses.23,24 Since 2006, the Pharmacy Outreach Program has helped thousands of older adults find affordable Part D plans. During the 2012 Part D open enrollment, 1,151 Medicare beneficiaries’ prescription drug plans were reviewed.25 Sixty-one percent of the beneficiaries were repeat clients, indicating that they found the service to be beneficial and necessary. Plan changes were recommended 57.3% of the time, and these recommended plans potentially saved beneficiaries an average of $517.00 in OOP costs over the course of one year.25
MedlinePlus and Computer Education Accessing quality information via the Internet can be a troubling endeavor for older adults with little technological experience. Through collaboration with MCPHS faculty members and the campus librarian, the Pharmacy Outreach Program helped create and initiate an educational program for older adults to learn how to search for health information on the Internet.26,27 Using computer classrooms at four local senior centers, older adults were taught to find reliable information on health, drugs, and supplements and evaluate the accuracy and reliability of health information Web sites.26 The three-lesson series was derived from the National Institute on Aging’s “Helping
Older Adults Search for Health Information Online: A Toolkit for Trainers.”28 Participants were instructed on how to use MedlinePlus, a Web site from the National Library of Medicine and the National Institutes of Health, to find health information.29 Pre- and post-lesson surveys were used to assess project objectives. Upon completion, participants surveyed indicated they were very likely to use MedlinePlus to find health information (83%) and information on drugs and supplements (79%).26 Sixty-five percent strongly agreed they felt more confident in their ability to evaluate the reliability of health information found on the Internet.26 A certificate was awarded to participants upon completion. The skills gained from this program will empower older adults to better manage their health. Pharmacists and organizations that do not have the resources to offer a full program such as this have the option to provide a shorter version of the sessions, highlighting just the “Drugs and Supplements” link of MedlinePlus, as an example. This shortened version could be offered within a 30-minute session at a senior center and allow opportunity for pharmacist interaction. Other resources are also available. National health theme initiatives such as Million Hearts Campaign and Script Your Future Medication Adherence Challenge are effective media promotions to include in standard outreach programs to further emphasize a particular health topic.30,31 Many national campaigns offer free, preprinted posters, medication wallet cards, and helpful handouts in lay language on numerous medication and health issues.31-33 Pharmacists can raise awareness on ways to optimize blood pressure control or campaign to increase medication adherence by supporting the mentioned campaigns.
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Clinical Note Pharmacy Student Education
Conclusion
In addition to providing services to the public, the Pharmacy Outreach Program educates pharmacy students during the advanced pharmacy practice experiential component of the MCPHS University Doctor of Pharmacy curriculum. Other groups and schools have similar programs to help students engage in the clinical care of geriatrics in the community.34,35 Students, under the supervision of licensed pharmacists, assist at the information call center and help clients improve their access to medications. This includes learning how to select Medicare Part D plans. During 2014 Medicare Part D open enrollment, 23 students were trained by licensed pharmacists in how to help select Medicare Part D plans and assist clients. Pharmacy students were surveyed prior to and after the learning experience, and the data suggest the impact of this experience was strongly positive for the student in understanding benefits, using the Medicare Part D plan finder tool, and increasing confidence in speaking to clients about their Medicare coverage. In addition, students, under the supervision of licensed pharmacists, are involved in some of the outreach events, helping provide medication therapy management services, and constructing and presenting programs that help educate the community. Students often address health promotion and disease prevention in the older adult and focus on adherence. Students become familiar with geriatric pharmacotherapy issues and learn to effectively communicate with older adults, developing confidence in educating the public. These opportunities help students understand and appreciate how valuable they can be in their own communities with health promotion activities upon graduation and licensing.
Pharmacists can engage in a number of innovative and effective outreach programs in the community to interact with older adults. The variety of these programs is unlimited, including engaging in direct patient care and offering various educational public health activities. These outreach events increase the visibility of pharmacists as health care providers, clinicians, and as sources of trusted information.
36
Paula Evans, PharmD, MS, CGP, is the director of the MCPHS University Pharmacy Outreach Program, and assistant professor of pharmacy practice, Worcester, Massachusetts. Timothy Dy Aungst, PharmD, is assistant professor of pharmacy practice, MCPHS University. Colleen Massey, MS, is director of operations, MCPHS University Pharmacy Outreach Program. Donna Bartlett, PharmD, CGP, is a clinical geriatric pharmacist, MCPHS University Pharmacy Outreach Program, and assistant professor of pharmacy practice, MCPHS University. For correspondence: Paula Evans, PharmD, MS, CGP, 19 Foster Street, Worcester, MA 01609; Phone: 508-373-5652; Fax: 508-3730032; E-mail: [email protected]. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2015 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2015.31.
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References 1. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother 2007;5:345-51. 2. Briesacher BA, Gurwitz JH, Soumerai SB. Patients at-risk for costrelated medication nonadherence: a review of the literature. J Gen Intern Med 2007;22:864-71. 3. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487-97. 4. Gellad WF, Grenard JL, Marcum ZA. A systematic review of barriers to medication adherence in the elderly: looking beyond cost and regimen complexity. Am J Geriatr Pharmacother 2011;9:11-23. 5. Bartlett D, Evans P, Sullivan M. Effect of a pharmacist-run call center on medication access for ambulatory care patients. Am J Health Syst Pharm 2009;66:1666-8. 6. Wick JY. Senior centers: traditional and evolving roles. Consult Pharm 2012;27:664-7. 7. Service-Learning and Civic Engagement Programs. MCPHS; Pharmacy Outreach Program. Available at http://www.mcphs.edu/ impact/community-service-programs/pharmacy-outreach-program. Accessed November 10, 2013. 8. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012;60:616-31. 9. Gallagher PF, O’Connor MN, O’Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther 2011;89:845-54. 10. Budnitz DS, Lovegrove MC, Shehab N et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 2011;365:2002-12. 11. Steinman MA, Handler SM, Gurwitz JH et al. Beyond the prescription: medication monitoring and adverse drug events in older adults. J Am Geriatr Soc 2011;59:1513-20. 12. Woelfel JA, Patel RA, Walberg MP et al. Use of potentially inappropriate medications in an ambulatory Medicare population. Consult Pharm 2011;26:913-9. 13. Tseng P, Bartlett D, Evans P et al. Importance of Medication Therapy Review in Geriatric Patients through Remote Access to Electronic Health Records as Part of the VNA Service. American Society of Health-System Pharmacists Mid-Year Clinical Meeting; Las Vegas, NV; December 2-6, 2012. 14. Huynh H, Nguyen R, Evans P et al. Designing a model to achieve cultural and linguistic competency with a minority population. Poster presented at the American Society of Health-System Pharmacists Mid-Year Clinical Meeting; Orlando, FL; December 8-12, 2013. 15. Tran T, Willett K, Durand C et al. Effect of pharmacist driven comprehensive medication management on elderly Hispanic patients. American Society of Health-System Pharmacists Mid-Year Clinical Meeting; Las Vegas, NV; December 2-6, 2012. 16. Zhou C, Zhang Y. The vast majority of Medicare Part D beneficiaries still don’t choose the cheapest plans that meet their medication needs. Health Affairs 2012;31:2259-65. 17. Medicare Prescription Drug Plans (PDPs). State Health Facts. Available at http://kff.org/medicare/state-indicator/prescriptiondrug-plans-pdps/. Accessed January 6, 2014.
18. Hunt Kearsley C, Upchurch G, Holmes GM et al. The other yearly checkup: your Medicare drug plan. J Am Pharm Assoc (2003) 2012;52:634-6. 19. Extra Help with Medicare Prescription Drug Plan Costs. Available at http://www.socialsecurity.gov/prescriptionhelp/. Accessed November 10, 2013. 20. State Pharmaceutical Assistance Programs. Available at http:// www.medicare.gov/pharmaceutical-assistance-program/stateprograms.aspx. Accessed January 6, 2014. 21. Specialized Health Care Programs in Massachusetts. Prescription Advantage. Available at http://www.massresources.org/prescriptionadvantage.html. Accessed November 10, 2013. 22. Li P, McElligott S, Bergquist H et al. Effect of the Medicare Part D coverage gap on medication use among patients with hypertension and hyperlipidemia. Ann Intern Med 2012;156:776-84. 23. Cutler TW, Stebbins MR, Smith AR et al. Promoting access and reducing expected out-of-pocket prescription drug costs for vulnerable Medicare beneficiaries: a pharmacist-directed model. Med Care 2011;49:343-7. 24. Alston G, Hanrahan C. Can a pharmacist reduce annual costs for Medicare Part D enrollees? Consult Pharm 2011;26:182-9. 25. Aungst T, Amzler B, Massey C et al. Impact of recommendations made by a pharmacy outreach program call center on costs of Medicare Part D plans for beneficiaries during open enrollment (abstract). JAPhA 2013;53:e92. 26. Lahoz MR, Wooding F, Evans P et al. A multidisciplinary educational series to help older adults find reliable online health information. Poster presented at the 2012 American Association of Colleges of Pharmacy Annual Meeting; Kissimmee, FL; July 1418, 2012. 27. Lahoz MR, Wooding F, Evans P et al. Results of hands-on computer lessons to teach the elderly to find authoritative health websites. Panel paper presented at the 2013 Medical Librarian Association (MLA) Annual Meeting; Boston, MA; May 3-8, 2013. 28. Helping Older Adults Search for Information Online: A Toolkit for Trainers. Available at http://nihseniorhealth.gov/toolkit/toolkit.html. Accessed December 27, 2013. 29. MedlinePlus. Available at http://www.nlm.nih.gov/medlineplus/. Accessed December 27, 2013. 30. Million Hearts. Available at http://millionhearts.hhs.gov/index. html. Accessed December 27, 2013. 31. Script Your Future. Available at http://www.scriptyourfuture.org/. Accessed December 27, 2013. 32. Health in Aging Tip Sheets. Available at http://www.healthinaging. org/news/tip-sheets/. Accessed January 6, 2014. 33. Choosing Wisely. Five Things Physicians and Patients Should Question. Available at http://www.healthinaging.org/files/documents/ tipsheets/TIPchoosing_wisely.pdf. Accessed January 6, 2014. 34. Patterson BY. An advanced pharmacy practice experience in public health. Am J Pharm Educ 2008;72:Article125. 35. Cutler TW, Stebbins MR, Lai E et al. Problem-based learning using the online Medicare Part D Plan Finder tool. Am J Pharm Educ 2008;72: Article 47.
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use to educate community-based older adults about health and medications. Setting: Events coordinated through MCPHS University Pharmacy Outreach Program and offered at Massachusetts senior centers. Practice Description: The MCPHS University Pharmacy Outreach Program, staffed with pharmacists, caseworkers, and pharmacy students, under the supervision of licensed pharmacists, provides free medication-related information to Massachusetts residents. Clients also receive assistance with cost-minimizing programs and insurance benefits. Seventy percent of contacts are older adults. Services are provided through a toll-free number and outreach programs. Practice Innovation: Focus on expanding educational health services and includes selecting Medicare D plans, working with support groups, providing medication management for diverse cultures, educating older adults on how to search for health information on the Internet, and discussing medication safety and adherence. Main Outcome Measurements: Participant and pharmacy student knowledge assessed utilizing survey tools. Additional measurements include savings for Medicare beneficiaries and improvements in medication management. Results: Observed results of the Pharmacy Outreach Program include decreased out-of-pocket costs for Medicare beneficiaries, improved medication adherence resulting in reduction of glycated hemoglobin and blood pressure, identifying and recommending medication treatment changes to reduce patient fall risk, and increased confidence in locating Web-based health information. Pharmacy students
demonstrated increased knowledge of and ability to communicate Medicare benefits. Conclusion: Outreach programs can improve older adults’ understanding about their health and medications. Pharmacists can increase visibility in the community by engaging in effective outreach programs. Key Words: Adherence, Community outreach, Cultural diversity, Falls, Medicare Part D, Medication therapy management, Older adult, Pharmacist, Pharmacy outreach program, Senior center, Student. Abbreviations: AD = Alzheimer’s disease, HbA1c = Glycated hemoglobin, OOP = Out-of-pocket, PD = Parkinson’s disease, PIM = Potentially inappropriate medications. Consult Pharm 2015;30:31-7.
Introduction Older adults are often encumbered with several comorbidities that require multiple medications. They can also be presented with complex daily drug regimens and potential side effects that may reduce their overall quality of life and lead to adverse outcomes.1 Additionally, out-of-pocket (OOP) costs of these medications may pose a financial burden, potentially decreasing their access to necessary treatment.2 Faced with multiple medications, side effects, and costs, some older adults find it difficult to take their medications as prescribed, and adherence becomes problematic.3,4 Pharmacists are well-positioned to address these issues given their clinical skills and exposure to high medication costs. Community outreach programs allow pharmacists to engage directly with older adults and address some of these concerns. Programs and services provided by pharmacists can improve upon the older adult’s knowledge of diseases and drugs and subsequently reinforce adherence. These programs put the pharmacist in an ideal position to help older adults overcome some of the barriers they face in taking care of their health.2,4 Pharmacists from community, hospital, and academic settings can coordinate with community organizations, such as senior centers, that serve this population. The MCPHS University Pharmacy
The Consultant Pharmacist january 2015 Vol. 30, No. 1
31
Clinical Note Outreach Program works with multiple senior centers and state-funded programs in Massachusetts to help address pharmaceutical issues of older adults in the community.5,6 Effective programs are defined for pharmacists looking to engage with a community-based older adult population about their health and medications. The aim of this paper is to share successful techniques pharmacists can use to educate community-based older adults about health and medications.
Practice Experience The MCPHS University School of Pharmacy Worcester/ Manchester operates a full-time Pharmacy Outreach Program where pharmacist faculty and case managers provide free medication-related educational services to the general public and health care practitioners in Massachusetts. This program was established in 2001 and is funded with a nonresearch service grant from the Commonwealth of Massachusetts, Executive Office of Elder Affairs, and several other community programming grants including existing contracts with Central Massachusetts Agency on Aging and the City of Boston. Funding is also obtained from local agencies, such as visiting nurse associations, on a per-patient consultation basis. It was among the first programs in the nation to address the need for assistance at a statewide level. While the program helps individuals of all ages, 70% of the clients served are older adults. Clients can access medication information and receive assistance with cost-related programs and insurance benefits through a toll-free number, the Internet, or outreach programs. Through the toll-free number, callers gain access to a team of pharmacists and case managers at the information call center who help them with insurance options, specialized outreach agencies, and assistance through pharmaceutical manufacturers. In addition, clinical pharmacists conduct medication reviews and provide counseling and compliance monitoring. Through the Pharmacy Outreach Program Web site, residents of Massachusetts are able to reach a pharmacist using the convenience of the Internet.7 “Ask the Pharmacist,” an e-mail link from the outreach program’s
32
Web site, allows pharmacists to respond to client information requests. In addition to the services offered through the helpline and the Internet, the program provides an array of educational programming throughout Massachusetts through other outreach programs that are created to fit the needs of patients, providers, and the overall community (Table 1). Some of the innovative programs and techniques used to reinforce the health message are detailed below and may offer an insight into programs or parts of programs that other pharmacists practicing in the community may be able to use. Additionally, consultant or other community pharmacists may have an opportunity to meet with other agencies and build expanded contacts when engaging in outreach programs. Working jointly with faculty members at a school of pharmacy or with pharmacy students may ease some of the time commitment and provide a wider range of services.
Outreach Programs Medication Safety and Medication Management Older adults in the community may be at risk for adverse events from their medications. Several drug criteria and tools (e.g., the Beers criteria, START/STOPP criteria) help identify potentially inappropriate medications (PIMs) with this population.8,9 Many of these PIMs are responsible for drug-related admissions to emergency departments.10 Pharmacists are in a prime position to help identify and educate individuals in the community on PIMs and general medication-related safety.11,12 Medication safety for the older adult is an important teaching point for the Pharmacy Outreach Program. Sessions at senior centers begin with a viewing of an inhouse-developed DVD highlighting safety concerning the correct way to take, store, and dispose of medications. Auxiliary labels are reviewed to help audience members understand how best to adhere to these special instructions. Following viewing of the DVD, there is a group discussion, then one-on-one medication counseling, including simplification of daily regimen and proper medication timing. The adults are told about key side effects
The Consultant Pharmacist january 2015 Vol. 30, No. 1
Expanding Clinical Information for Older Adults In the Community
Table 1. Outreach Programs Offered by the MCPHS University Pharmacy Outreach Program Service
Type
Medication Safety
DVD, Presentation
Medication Management
DVD, Presentation
“Ask the Pharmacist”
Consultation
Senior Center Health Fairs
Informational
Fall Prevention
Presentation
Medicare Education
Presentation
Medicare Part D Evaluations
Consultation
MedlinePlus
Learning Series
MTM for Diverse Cultures
Consultation
Health Condition or Disease-Specific Education
Presentation
• Low-Vision Support Groups • Parkinson’s and Alzheimer’s Disease MTM
Consultation
Abbreviation: MTM = Medication therapy management.
and educated on what to do should they occur. A second DVD has been developed concentrating on medication management and medication adherence. In this DVD, pill organization, understanding the need of medication therapy, and incorporating medications as a part of a daily routine are addressed. These short, 8-to-12-minute DVDs focus the audience and allow for interesting question and review. Patient knowledge is assessed through the use of postprogram surveys. The data indicate that the programming has a highly positive impact on the patients’ understanding of their medications, safety, and adherence.
Education on Fall Prevention Preventing falls is an important subject for pharmacists to discuss with older adults and various health care providers. Specific programs have been developed targeting each audience. During community presentations, older adults are taught that falls are multifactorial and that some
medications may increase their risk. Medications are evaluated and suggestions made for better, safer alternatives. The Pharmacy Outreach Program also provides continuing education sessions for health professionals, including nurses and physical therapists, to raise awareness of medications that may increase fall risk and introduce criteria to help assess the medications of their patients.10,11 These educational sessions often prompt the attendees to recommend a pharmacist review the medication profile for potential interventions. Finally, the Pharmacy Outreach Program consults for several organizations in the region through contracts on a patient-fee basis. Pharmacists are part of a fall-risk reduction program for recently hospitalized patients discharged into a visiting nurse association service, and review patient profiles for PIMs.13 This is accomplished through remote access to electronic health records. Pharmacists’ recommendations are documented in the visiting nurse records and can then be viewed by connecting health care
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Clinical Note personnel. Pharmacists reviewed records of 100 patients (65% female, mean age 84 ± 6 standard deviation), assessing the types and number of medication interventions and clarifying dosing and durations of treatment. Interventions included appropriateness of proton-pump inhibitor use (32%), medication treatment suggestions (20%), and vitamin D/calcium suggestions (16%).13 Clinical pharmacists, as part of a visiting nurse association service, can identify medication-related problems through remote access to patients’ electronic medical records and help prevent possible adverse outcomes.
Cultural Group Services at Senior Centers Senior centers provide opportunities for older adults of different cultural backgrounds to gather. Within the service area of the Pharmacy Outreach Program, there are weekly social networking and activity programs for the Vietnamese, Chinese, Iraqi, Latino, and Portuguese cultural groups. The pharmacy program is promoted by connecting with a staff member at the senior center who coordinates services for the group, announcing all pharmacy services with a poster in the native language, offering educational programs to the group first and individual medication reviews second, using students or providers who speak the native language and know the culture and habits. This model was followed working with 50 nonEnglish-speaking older adults of Vietnamese ethnicity.14 Educational presentations were offered on adherence, healthy food substitution in Asian diets, and supplements and medications in diabetes and hypertension. Medication reviews were completed for all participants, and personal medication charts were compiled and transcribed into Vietnamese. Preliminary survey data suggest participants strongly agree that the information provided improves understanding of diseases, medications, and the importance of adherence.14 In another series of programs focusing on non-English-speaking older adults (Hispanic), pharmacist-led medication management was beneficial in improving health outcomes by providing continuity of care between physician visits.15 Monthly screening and education over a four-month period assessed changes in blood pressure and glycated hemoglobin (HbA1c) as a result of management of chronic conditions. Participants
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experienced lowering of blood pressure and HbA1c after four months.15
Social Support Groups at Senior Centers Senior centers provide opportunities for health-related social support groups to gather. The Pharmacy Outreach Program has discussed issues pertaining to low vision, Parkinson’s disease (PD), and Alzheimer’s disease (AD), and communities can connect with other support groups. These are interactive, friendly gatherings that often include patients and supporting family and friends. They usually meet monthly and look for speakers who can offer assistance and education on health-related topics. For the low-vision population, pharmacy students, under the supervision of licensed pharmacists from the Pharmacy Outreach Program, discuss how to organize and take medications safely when dealing with challenges associated with macular degeneration, glaucoma, and cataracts. PD groups have requested help with proper medication timing and how to best afford medications with certain Medicare D prescription insurance plans. AD groups are interested in alternative and natural products that may help with the disease process. Additionally, brown bag reviews are encouraged at all programs. Pharmacists serve as mediators for questions and discussion among group members while providing appropriate and reliable information. Medicare Training and Patient Plan Evaluation The Medicare Part D benefit design is complicated and often confusing for many older adults, and the system leads many to select inappropriate plans.16 Plans change from year to year, and beneficiaries in Massachusetts often have more than 30 stand-alone Part D plans from which to choose.17 Each private Part D plan sponsor can make changes to the plan’s cost-sharing structure (monthly premium, deductible, coinsurance) and formulary, including utilization and cost-control mechanisms (step therapy, prior authorization, and quantity limit). Many older adults benefit from educational sessions that help them understand the impact of the yearly changes.18 To address the need for clear, comprehensive, and up-to-date information, Pharmacy Outreach Program presentations are held throughout the state in the fall of each year.
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These sessions focus on educating older adults on the benefit design, eligibility and enrollment guidelines, additional assistance options, and changes to expect in the upcoming benefit year. Beneficiaries may unknowingly qualify for additional secondary assistance to help cover the costs of Medicare Part D and require guidance with signing up for these programs. These programs include a federal assistance program through the Social Security Administration called “Extra Help” or a state pharmaceutical assistance program such as Prescription Advantage in Massachusetts.19-21 Additionally, Medicare Part D openenrollment events are held each fall to offer beneficiaries an opportunity to evaluate their plan options with trained pharmacists, pharmacy students, and case managers. OOP expenses are a barrier to medication access for older adults covered by Part D, resulting in poor adherence and disease outcomes.22 Pharmacists have previously proven the viability of performing Part D yearly reviews and reducing OOP expenses.23,24 Since 2006, the Pharmacy Outreach Program has helped thousands of older adults find affordable Part D plans. During the 2012 Part D open enrollment, 1,151 Medicare beneficiaries’ prescription drug plans were reviewed.25 Sixty-one percent of the beneficiaries were repeat clients, indicating that they found the service to be beneficial and necessary. Plan changes were recommended 57.3% of the time, and these recommended plans potentially saved beneficiaries an average of $517.00 in OOP costs over the course of one year.25
MedlinePlus and Computer Education Accessing quality information via the Internet can be a troubling endeavor for older adults with little technological experience. Through collaboration with MCPHS faculty members and the campus librarian, the Pharmacy Outreach Program helped create and initiate an educational program for older adults to learn how to search for health information on the Internet.26,27 Using computer classrooms at four local senior centers, older adults were taught to find reliable information on health, drugs, and supplements and evaluate the accuracy and reliability of health information Web sites.26 The three-lesson series was derived from the National Institute on Aging’s “Helping
Older Adults Search for Health Information Online: A Toolkit for Trainers.”28 Participants were instructed on how to use MedlinePlus, a Web site from the National Library of Medicine and the National Institutes of Health, to find health information.29 Pre- and post-lesson surveys were used to assess project objectives. Upon completion, participants surveyed indicated they were very likely to use MedlinePlus to find health information (83%) and information on drugs and supplements (79%).26 Sixty-five percent strongly agreed they felt more confident in their ability to evaluate the reliability of health information found on the Internet.26 A certificate was awarded to participants upon completion. The skills gained from this program will empower older adults to better manage their health. Pharmacists and organizations that do not have the resources to offer a full program such as this have the option to provide a shorter version of the sessions, highlighting just the “Drugs and Supplements” link of MedlinePlus, as an example. This shortened version could be offered within a 30-minute session at a senior center and allow opportunity for pharmacist interaction. Other resources are also available. National health theme initiatives such as Million Hearts Campaign and Script Your Future Medication Adherence Challenge are effective media promotions to include in standard outreach programs to further emphasize a particular health topic.30,31 Many national campaigns offer free, preprinted posters, medication wallet cards, and helpful handouts in lay language on numerous medication and health issues.31-33 Pharmacists can raise awareness on ways to optimize blood pressure control or campaign to increase medication adherence by supporting the mentioned campaigns.
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Clinical Note Pharmacy Student Education
Conclusion
In addition to providing services to the public, the Pharmacy Outreach Program educates pharmacy students during the advanced pharmacy practice experiential component of the MCPHS University Doctor of Pharmacy curriculum. Other groups and schools have similar programs to help students engage in the clinical care of geriatrics in the community.34,35 Students, under the supervision of licensed pharmacists, assist at the information call center and help clients improve their access to medications. This includes learning how to select Medicare Part D plans. During 2014 Medicare Part D open enrollment, 23 students were trained by licensed pharmacists in how to help select Medicare Part D plans and assist clients. Pharmacy students were surveyed prior to and after the learning experience, and the data suggest the impact of this experience was strongly positive for the student in understanding benefits, using the Medicare Part D plan finder tool, and increasing confidence in speaking to clients about their Medicare coverage. In addition, students, under the supervision of licensed pharmacists, are involved in some of the outreach events, helping provide medication therapy management services, and constructing and presenting programs that help educate the community. Students often address health promotion and disease prevention in the older adult and focus on adherence. Students become familiar with geriatric pharmacotherapy issues and learn to effectively communicate with older adults, developing confidence in educating the public. These opportunities help students understand and appreciate how valuable they can be in their own communities with health promotion activities upon graduation and licensing.
Pharmacists can engage in a number of innovative and effective outreach programs in the community to interact with older adults. The variety of these programs is unlimited, including engaging in direct patient care and offering various educational public health activities. These outreach events increase the visibility of pharmacists as health care providers, clinicians, and as sources of trusted information.
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Paula Evans, PharmD, MS, CGP, is the director of the MCPHS University Pharmacy Outreach Program, and assistant professor of pharmacy practice, Worcester, Massachusetts. Timothy Dy Aungst, PharmD, is assistant professor of pharmacy practice, MCPHS University. Colleen Massey, MS, is director of operations, MCPHS University Pharmacy Outreach Program. Donna Bartlett, PharmD, CGP, is a clinical geriatric pharmacist, MCPHS University Pharmacy Outreach Program, and assistant professor of pharmacy practice, MCPHS University. For correspondence: Paula Evans, PharmD, MS, CGP, 19 Foster Street, Worcester, MA 01609; Phone: 508-373-5652; Fax: 508-3730032; E-mail: [email protected]. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2015 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2015.31.
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18. Hunt Kearsley C, Upchurch G, Holmes GM et al. The other yearly checkup: your Medicare drug plan. J Am Pharm Assoc (2003) 2012;52:634-6. 19. Extra Help with Medicare Prescription Drug Plan Costs. Available at http://www.socialsecurity.gov/prescriptionhelp/. Accessed November 10, 2013. 20. State Pharmaceutical Assistance Programs. Available at http:// www.medicare.gov/pharmaceutical-assistance-program/stateprograms.aspx. Accessed January 6, 2014. 21. Specialized Health Care Programs in Massachusetts. Prescription Advantage. Available at http://www.massresources.org/prescriptionadvantage.html. Accessed November 10, 2013. 22. Li P, McElligott S, Bergquist H et al. Effect of the Medicare Part D coverage gap on medication use among patients with hypertension and hyperlipidemia. Ann Intern Med 2012;156:776-84. 23. Cutler TW, Stebbins MR, Smith AR et al. Promoting access and reducing expected out-of-pocket prescription drug costs for vulnerable Medicare beneficiaries: a pharmacist-directed model. Med Care 2011;49:343-7. 24. Alston G, Hanrahan C. Can a pharmacist reduce annual costs for Medicare Part D enrollees? Consult Pharm 2011;26:182-9. 25. Aungst T, Amzler B, Massey C et al. Impact of recommendations made by a pharmacy outreach program call center on costs of Medicare Part D plans for beneficiaries during open enrollment (abstract). JAPhA 2013;53:e92. 26. Lahoz MR, Wooding F, Evans P et al. A multidisciplinary educational series to help older adults find reliable online health information. Poster presented at the 2012 American Association of Colleges of Pharmacy Annual Meeting; Kissimmee, FL; July 1418, 2012. 27. Lahoz MR, Wooding F, Evans P et al. Results of hands-on computer lessons to teach the elderly to find authoritative health websites. Panel paper presented at the 2013 Medical Librarian Association (MLA) Annual Meeting; Boston, MA; May 3-8, 2013. 28. Helping Older Adults Search for Information Online: A Toolkit for Trainers. Available at http://nihseniorhealth.gov/toolkit/toolkit.html. Accessed December 27, 2013. 29. MedlinePlus. Available at http://www.nlm.nih.gov/medlineplus/. Accessed December 27, 2013. 30. Million Hearts. Available at http://millionhearts.hhs.gov/index. html. Accessed December 27, 2013. 31. Script Your Future. Available at http://www.scriptyourfuture.org/. Accessed December 27, 2013. 32. Health in Aging Tip Sheets. Available at http://www.healthinaging. org/news/tip-sheets/. Accessed January 6, 2014. 33. Choosing Wisely. Five Things Physicians and Patients Should Question. Available at http://www.healthinaging.org/files/documents/ tipsheets/TIPchoosing_wisely.pdf. Accessed January 6, 2014. 34. Patterson BY. An advanced pharmacy practice experience in public health. Am J Pharm Educ 2008;72:Article125. 35. Cutler TW, Stebbins MR, Lai E et al. Problem-based learning using the online Medicare Part D Plan Finder tool. Am J Pharm Educ 2008;72: Article 47.
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