Improving Medication Management Practices and Care Transitions through Technology (New York)

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Summary:

The home health care industry is comprised of over 10,000 Medicare-certified home health agencies (HHAs) that provide post-acute and long-term care services to a heterogeneous population. Home health patients, who are disproportionately female and elderly, are clinically diverse and especially vulnerable by virtue of their advanced age, multiple co-morbid conditions, and functional dependencies. Skilled nursing care is the core service provided by HHAs, which conducted more than 121 million home health visits with Medicare beneficiaries in 2008.

This project examined the relative effectiveness and cost-effectiveness of a health information technology (IT) intervention designed to facilitate high-quality care transitions to home health care. The project developed a medication management system intended to improve clinician practice by providing clinical decision support (CDS) and to enhance patient engagement by providing supplementary information to patients with complex medication regimens. The study took place at a large, urban, non-profit home health care organization in the New York City region.

The specific aims of this project were to:

  • Examine the relative effect of the intervention on workflow and medication management practices of home health care nurses. 
  • Examine the relative effect of the intervention on the outcomes and service use of patients in the respective study groups. 
  • Estimate the costs associated with the intervention and subsequent care and compare these costs relative to usual care. 

The project used a randomized trial to evaluate the effectiveness of the IT intervention to improve medication management for patients with complex medication regimens. The intervention tested an automated algorithm that identified high-risk patients and sent an email alert to the home health nurse shortly after the patient’s admission to home care. It also provided the nurse with medication decisionmaking support, including high-risk medication management recommendations that were integrated into the clinician’s visit documentation system and the patient’s electronic health record. The system was evaluated by comparing the intervention to a usual care group. Five hundred nurses were enrolled in the study, with 33 percent randomized to the intervention arm. A total of 7,919 patients were also enrolled, with 32 percent in the intervention arm.

A survey was administered to a subset of 826 participants. The results did not show improvements in the process of care, patient knowledge of medications, or patient medication management. However, within the intervention group, nurses’ use of CDS was associated with significantly more patients moving below the medication complexity risk threshold and lower patient hospitalization rates.

Use of the CDS by nurses was variable, likely due in part to variations in the nurses’ level of comfort with the different care management practices embedded in the CDS tool or with variations in their comfort with the IT system itself. The more patients a nurse had in the study, the more likely the nurse was to use the tool. Several patient characteristics also predicted CDS use by the nurse. The CDS was more likely to be used among patients with a longer length of home care service and more nurse visits. Nurses used the tool more often with patients who took a greater number of medications. This study provides new information on the predictors of CDS use and the impact of CDS use on patient outcomes in this population. Strategies to increase use of CDS tools need further exploration to provide greater benefit to more patients.

Improving Medication Management Practices and Care Transitions through Technology - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017837
  • Project Period: 
    September 2008 – September 2012
  • AHRQ Funding Amount: 
    $1,199,998
  • PDF Version: 
    (PDF, 296.62 KB)

Summary: The overall aims of this project were to examine the relative effectiveness and cost-effectiveness of a health information technology (IT) intervention designed to facilitate high-quality care transitions to home health care. The project developed a medication management system intended to improve clinician practice and enhance patient engagements by identifying patients with complex medication regimens, providing clinical decision support (CDS) for clinicians, and providing supplementary information to patients.

The intervention tested an automated algorithm to identify high-risk patients and send an email alert to the home health nurse shortly after the patient’s admission to home care. It also provided the nurse with medication decisionmaking support, including high-risk medication management recommendations that were integrated into the clinician’s visit documentation system and the patient’s electronic health record. The nurses of eligible patients were randomized to a usual care group or an intervention group on a rolling basis at a 2-to-1 ratio. Once randomized, the study arm assignment did not change, and all eligible patients of a particular nurse were included in the same study arm as the nurse’s randomization assignment. A sub-sample of eligible patients whose nurses were randomized into the study was recruited to complete in-home surveys that provided additional information on process of care and outcomes.

The health IT system was evaluated by comparing the intervention arm to the usual care group. This project was an extension of the existing Visiting Nurse Service of New York (VNSNY) health IT system and had many of the features that the home health nurses use regularly.

Specific Aims:

  • Examine the relative effect of the intervention on workflow and medication management practices of home health care nurses. (Achieved) 
  • Examine the relative effect of the intervention on the outcomes and service use of patients in the respective intervention groups. (Achieved) 
  • Estimate the costs associated with the intervention and subsequent care and compare these costs relative to usual care. (Achieved) 

2012 Activities: Study enrollment and implementation of the intervention began in February 2010 and concluded in 2011. In 2012, the analysis team focused on obtaining secondary data, data cleaning, and data analysis. The analysis looked at whether the intervention: 1) changed the complexity score of the medication regimen; 2) reduced the number of hospitalizations; and 3) reduced the number of emergency room (ER) visits.

Due to changes in staffing and the complexity of the analyses, the team used a 1-year no-cost extension to complete the data analyses. As last self-reported in the AHRQ Research Reporting System, project progress was completely on track and budget spending was on target. This project ended in September 2012.

Impact and Findings: Five hundred nurses were enrolled in the study. Of these, 165 (33 percent) were randomized to the intervention arm. A total of 7,919 patients were included in the study, with 2,550 (32 percent) in the intervention arm. The primary analyses did not find reductions in the medication complexity score, hospitalizations, or ER visits.

A survey administered to a subset of 826 participants did not identify improvements in the process of care, patient knowledge of medications, or patient medication management. However, within the intervention group, nurses’ use of CDS was associated with significantly more patients moving below the medication complexity risk threshold and significantly lower patient hospitalization rates. The most frequent documented actions of nurses using the CDS were nurses advising the patient to keep his/her medication list up-to-date and to bring the list to his/her doctors’ appointments. Far fewer records indicated that the nurse advised the patient to speak with the doctor about simplifying his/her medication regimen, and only a small number of records indicated that the nurse reached out to the doctor directly to work on simplification.

Dr. Feldman hypothesizes that observed variations in CDS use likely were due in part to variations in the nurses’ level of comfort with the different care management practices embedded in the CDS tool or with variations in their comfort with the IT system itself. Support for this hypothesis is provided by the nurse characteristics that were predictive of CDS use among nurses in the intervention group. Nurses with more experience at the VNSNY and those who were in salaried staff positions (versus per diem nurses) were more likely to use the tool at least once. Furthermore, the more patients a nurse had in the study, the more likely the nurse was to use the CDS tool.

Several patient characteristics also predicted CDS use by the nurse. The CDS was more likely to be used the longer patients were in home care service and the more nurse visits they had. This may have been because the nurse had more opportunity to use the tool or it may have been a result of using the tool. Nurses used the tool more often with patients who took a greater number of medications. While all patients for whom the nurses received an alert had complex medication regimens, it is possible that nurses were more concerned about patient risk when the number of medications taken was higher.

This study provides new information on the predictors of CDS use and the impact of CDS use on patient outcomes. Strategies to increase use of CDS tools need further exploration in order to provide greater benefit to more patients.

Target Population: Adults, Chronic Care*, Elderly*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ’s priority populations.

Improving Medication Management Practices and Care Transitions through Technology - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017837
  • Project Period: 
    September 2008 - September 2012
  • AHRQ Funding Amount: 
    $1,199,998
  • PDF Version: 
    (PDF, 199.82 KB)

Summary: The overall aims of this project are to examine the relative effectiveness and cost-effectiveness of a health information technology (IT) intervention designed to facilitate high-quality care transitions to home health care. The project developed a medication management system intended to improve clinician practice and enhance patient engagements by identifying patients with complex medication regimens, providing electronic decision support for clinicians, and providing supplementary information to patients. The intervention being tested uses an automated algorithm to identify high-risk patients and send an email alert to the home health nurse shortly after the patient's admission to home care. It also provides the nurse with medication decisionmaking support, including high-risk medication management recommendations that are integrated into the clinician's visit documentation system and the patient's electronic health record. The patient receives educational materials as part of the intervention. The health IT system will be evaluated by comparing the intervention arm to the usual care group in a randomized controlled trial. This project is an extension of the existing Visiting Nurse Service of New York health IT system and uses many of the features that the home health nurses regularly use.

Specific Aims:

  • Examine the relative effect of the intervention on workflow and medication management practices of home health care nurses. (Ongoing)
  • Examine the relative effect of the intervention on the outcomes and service use of patients in the respective intervention groups. (Ongoing)
  • Estimate the costs associated with the intervention and subsequent care and compare these costs relative to usual care. (Ongoing)

2011 Activities: Implementation of the intervention began in February 2010. In 2011, an automated process was set up to calculate a medication regimen complexity index score using electronic medication information that is collected as part of usual care. The nurses of eligible patients were randomized to the usual care group and intervention group on a rolling basis at a two-to-one ratio. Once randomized, the study arm assignment did not change, and all eligible patients of a particular nurse were included in the same study arm as the nurse's randomization assignment. A subsample of eligible patients whose nurses were randomized into the study was recruited to complete in-home surveys that provided additional information on process of care and outcomes.

The analysis team focused on obtaining data, data cleaning, and data analysis. Two sets of analyses were planned. The first analysis, which has been completed, used the full sample size of all of the patients who were randomized. This analysis looked at whether the intervention: 1) changed the complexity score of the medication regimen; 2) reduced the number of hospitalizations; and 3) reduced the number of emergency room visits. The second analysis, which is currently in progress, is looking at the same endpoints as the first analysis; however, sample size is limited to the patients that participated in an interview. This second analysis will incorporate user data with the interview data.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are on track and project spending is roughly on target. Due to changes in staffing and the complexity of the analyses, the team is using a 1-year no-cost extension to complete the data analyses.

Preliminary Impact and Findings: Five-hundred nurses were enrolled in the study. Of these, 165 (33 percent) were randomized to the intervention arm. A total of 7,960 patients were included in the study, with 2,562 (32 percent) in the intervention arm. Patient outcome interviews were conducted among a randomly-selected subset of patients on a one-to-one basis, approximately 60 days after home care admission. The final survey group included 826 patients, 423 (51 percent) of which were selected from the intervention arm.

Descriptive statistics indicated that the demographic characteristics of nurses and patients were evenly distributed across the two study arms. Analysis of the intervention nurses' use of the electronic decision support tool and the effect of the intervention on patient outcomes is in progress.

Target Population: Adults, Chronic Care*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

Improving Medication Management Practices and Care Transitions through Technology - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017837
  • Project Period: 
    September 2008 – September 2011
  • AHRQ Funding Amount: 
    $1,199,198
  • PDF Version: 
    (PDF, 308.33 KB)


Target Population: Adults, Chronic Care*

Summary: The overall aims of this project are to examine the relative effectiveness and cost-effectiveness of a health information technology (IT) intervention designed to identify patients with complex and/or high-risk medication regimens, provide electronic decision support for clinicians, and provide supplementary information to patients, thereby improving nursing practices and patient outcomes. This project has designed a medication management system to facilitate high-quality care transitions through improved clinician practice and enhanced patient engagement. The intervention to be tested uses an automated algorithm to identify high risk patients and to send an email alert to the home health nurse shortly after the patient’s admission to home care. This intervention also provides the nurse with decision support, including high-risk medication management recommendations that are integrated into the clinician’s visit documentation system and the patient’s electronic health record. The patient also receives educational materials as part of the intervention. The health IT system will be evaluated by comparing the intervention arm to the usual care group in a randomized controlled trial. This project is an extension of the existing Visiting Nurse Service of New York health IT system and uses many of the features that the home health nurses regularly use.

Specific Aims:
  • Examine the relative effect of the intervention on workflow and medication management practices of home health care nurses. (Ongoing)
  • Examine the relative effect of the intervention on the outcomes and service use of patients in the respective intervention groups. (Ongoing)
  • Estimate the costs associated with the intervention and subsequent care and compare these costs relative to usual care. (Upcoming)

2010 Activities: Implementation of the intervention began in February 2010. An automated process was set up to calculate a Medication Regimen Complexity Index score using electronic medication information that is collected as part of usual care. The nurses of eligible patients were randomized to the usual care group and intervention group on a rolling basis at a two-to-one ratio. Once randomized, the study arm assignment did not change, and all eligible patients of a particular nurse were included in the same study arm as the nurse’s randomization assignment. The randomization process ended in October 2010 with the enrollment of 500 nurses who were each following at least one patient included in the study. Of these nurses, 165 (33 percent) were randomized to the intervention study arm. A total of 7,960 patients were included in the study, with 2,562 (32 percent) in the intervention arm. Patient outcome interviews were conducted among a randomly selected subset of patients on a one-to-one basis, approximately 60 days after home care admission. The final survey group included 826 patients, 423 (51 percent) of which were selected from the intervention arm.

The analysis team is currently focused on defining variables and obtaining study data from additional sources. An initial data abstraction from the electronic medical record was completed. This abstraction provides information from the decision support tool, including documentation of patient education regarding how to manage complex medication regimens. The full clinical record abstraction and additional datasets are being obtained to describe utilization of home care service and changes in medication regimens. Final data downloads will begin in January 2011 to enable the analysis of study data.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): The project is on time on all tasks. Spending is roughly on target.

Preliminary Impact and Findings: The project has no findings to date.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

*AHRQ Priority Population.

Improving Medication Management Practices and Care Transitions through Technology - Final Report

Citation:
Feldman P. Improving Medication Management Practices and Care Transitions through Technology - Final Report. (Prepared by Visiting Nurse Service of New York under Grant No. R18 HS017837). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 294.76 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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