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Medication adherence is an ongoing challenge, particularly in geriatrics. Understanding medication regimens and following those regimens is often difficult for older adults. Polypharmacy exacerbates nonadherence with pharmacologic therapy. The number of prescriptions written for older adults is more than twice that of the national population and nearly three times that of people younger than 65.1 The term polypharmacy is typically applied to a regimen of four or more prescribed drugs.2
Comprehensive medication therapy management can help manage chronic disease and drug-related issues in older patients. Research shows that medication management programs for chronic conditions can be improved through collaboration between primary care clinicians and pharmacists.3 Patient interaction with pharmacists can translate into improvements in health status and in cost reductions. Pharmacist involvement with individual patients is pivotal to improve medication regimen adherence.
The Project
This article describes an NP-driven project that implemented a collaboration involving primary care clinicians, nurses and pharmacists who provided healthcare in an outpatient geriatric practice in Charlotte, N.C. Selected patients were on a regimen of four or more medications, had a diagnosis of uncontrolled diabetes mellitus, hypertension and/or hyperlipidemia, and had expressed confusion about their medication regimens.
Purpose and Methods
Evidence supports pharmaceutical counseling as a method of reducing the risk of medication nonadherence and errors.4 This quality improvement project sought to address the risk of medication nonadherence for older patients in an outpatient clinic. The goal was to evaluate the results of pharmaceutical counseling on objective outcomes of low-density lipoprotein (LDL), A1c and blood pressure levels in patients with hyperlipidemia, diabetes and hypertension. We sought to equip patients with greater understanding of their medication regimens.
The evidence that pharmaceutical counseling can reduce chronic disease indicators in older adults on polypharmacy regimens was the basis for this project.5 Pharmacists reviewed each patient's medication list and answered questions about it. They discussed with patients the best time of day to take their medications and discussed combination options that could increase adherence and limit daily dosing.
The patients were then seen by the nurse practitioner, who reviewed these suggestions with the patient. Five months after the initial counseling visit, patients had a follow-up visit with the pharmacist to address additional questions. Their disease indicators were evaluated at that time. The model for this program has been used in North Carolina to assist patients in understanding their medication regimens in various settings.
This project promotes the Institute of Medicine's six goals for evidence-based medicine: patient centeredness, effectiveness, efficiency, safety, timeliness and equitability.6 LDL, A1c and blood pressure were chosen as objective measures to determine outcome results. These chronic disease markers were selected because pharmaceutical counseling has often been suggested as a way to combat medication nonadherence in the outpatient primary care setting. One study found that pharmaceutical counseling reduced LDL, glucose and blood pressure readings in patients in an outpatient setting.7
Methods
A community hospital outpatient clinic specializing in geriatrics, Presbyterian Hospital Seniorhealth, was the site for this project. It had more than 5,000 established patients ages 60 years and older. A needs assessment was conducted to determine the percentage of patients taking four or more prescriptions medications, and about 60% of the patients met these criteria, placing them at risk for medication errors and nonadherence.
Study participants were randomly selected from the patients who met the criteria for inclusion: polypharmacy and diagnosis of one of the specified chronic diseases.
Referrals began in September 2008 and continued until March 2009. After informed consent was provided, patients were referred to the telephone pharmaceutical counseling program. Patients who did not speak English were excluded because no translator was available. One hundred twenty-one patients were referred to the project.
Intervention
Presbyterian Hospital's pharmaceutical counseling program, SafeMed, provided the telephone-based counseling. SafeMed pharmacists follow the Beers criteria to determine safe medications for older adults. These criteria clearly guide the pharmacist in advising the patient and clinician on safe regimens. Therefore, the telephone counseling with these study participants focused on reviewing medication regimens, determining the most appropriate times to take the medications and clarifying questions or concerns  about their specific medication regimens.
When a question arose about any patient's medication regimen, a note was faxed to the patient's primary care provider and the clinician followed up accordingly with the patient at an office visit. The hospital's Clinical Improvement Committee acted as an avenue for reporting objective outcome results at the conclusion of the project.
After each counseling session, the pharmacist provided a note to the nurse practitioner containing an overview of the counseling suggestions and any medication changes or laboratory tests that were needed. This note was filed in the patient's chart. When following up with the primary care provider, the patient and provider reviewed the suggestions provided by the pharmacist
At the conclusion of each telephone counseling session, the patients received a mailed survey to evaluate their experience with the counseling session. They were asked to return the surveys to their primary care provider. The pharmacists made sure that patients scheduled follow-up appointments with their respective clinicians. At each follow-up visit, the nurse practitioner also reviewed medications and addressed any concerns or questions.
At the follow-up visit with the NP, adherence to medication regimens was reviewed and the list of prescribed medications was compared with what the patient was actually taking, as reported by the pharmacist. Blood pressure, A1c and cholesterol measurements were taken as a baseline before the consulting session and compared with readings 5 months after the initial session with the pharmacist. In the majority of this population, these chronic disease indicators improved. These objective outcomes suggest better chronic disease management. Objective outcomes of outpatient drug therapy are especially important when addressing medication management in older patients.8
Barriers
In the early stages of implementation, reports from the SafeMed pharmacists, which included recommendations for the NP, were embedded in the pharmaceutical consult note and were overlooked. This occurred due to the layout of the note. SafeMed pharmacists then began placing the recommendations on a separate section of the form, which made it more visible to the NP.
The decision was also made to emphasize to the nursing staff the importance of placing the pharmaceutical consult notes on patient charts and bringing these notes to the provider, advising the clinician of the new recommendation section on the form.
Outcomes
Patient satisfaction with counseling was determined using the patient survey. Patients were asked if they found the counseling helpful in understanding their medication regimen and if their medication questions were adequately addressed. Patients were also asked if as a result of the counseling session, they had changed the time of the day they take their medications for greater efficacy. Finally, patients were given an opportunity to comment on their individualized drug therapy counseling.
The satisfaction rate averaged 95%. Patients' only complaint was the delay between the referral and the counseling; they wanted to be seen sooner. Although many of the patients referred to pharmaceutical counseling did not understand their personal medication regimens, 90% confirmed that they understood the indications of their medications after the pharmaceutical counseling.
Outcomes were determined through a random review of the charts on the patients referred to counseling. Chart reviews are an effective means to review outcomes of quality improvement projects in outpatient settings.9 Results were determined by comparing A1c, LDL and blood pressure values with precounseling values.
A sample of 30% of the patients was chosen to determine an overview of the outcomes. Forty charts were selected from the 121 patients who participated.
Twenty-one of the 40 charts selected were patients with previously uncontrolled diabetes. Of these, three had A1c levels outside the 5.5 to 7.0 acceptable range,10 and the rest had stable A1c levels. Five of the patients actually experienced improvement of 1.0 points in A1c.
Thirty-six of the 40 charts were for patients with previously uncontrolled hypertension. Of these, 30 achieved blood pressure levels that were within the JNC7 guidelines (not greater than 140/90 mm Hg).11 Over the 6 months of pharmacist counseling, four had seen improvement in their readings but fell outside the JNC 7 guidelines. Two had blood pressure readings that had worsened over the year, and their levels were well above the accepted guidelines. One of these patients declined medication for his blood pressure, thus the uncontrolled hypertension.
Thirty-five of the charts were for patients with previously uncontrolled hypercholesterolemia. Thirty-four had LDL levels < 130 mg/dL, which is within acceptable range. Only one patient had levels that were above the recommended reading, and this patient had declined treatment, choosing a lifestyle approach to combat an LDL level of 170 mg/dL.
Conclusion
This NP-driven project implemented the evidence-based approach of pharmaceutical counseling in an outpatient setting to improve medication adherence and achieve improvement in chronic disease indicators. The implementation of pharmaceutical counseling with collaborating professionals is an effective method of improving medication regimen efficacy and adherence.12 This is especially important in older adults, who are at risk for nonadherence due to multidrug regimens for chronic disease.13
The objective outcomes of pharmaceutical counseling obtained from a chart review showed improvement in chronic disease indicators, as well as greater patient satisfaction and understanding of individual drug regimens.
These outcomes seem to substantiate the existing evidence that collaborative pharmaceutical counseling in a primary care setting is correlated with improved outcomes. Presbyterian Hospital's Clinical Improvement Committee agreed on the value of this project and sought further grant funding for SafeMed outpatient pharmaceutical counseling.
Kristene Diggins is a family and gerontologic nurse practitioner who practices in retail health in Charlotte, N.C.
References
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2. Hayes TL, et al. Medication adherence in healthy elders: small cognitive changes make a big difference. J Aging Health. 2009;21(4):567-580.
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4. More than 1.5 million Americans sickened, injured or killed by medication errors each year; seniors most at risk. DailyMed. http://www.dailymedrx.com/media/DailyMedLaunchRelease.pdf
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6. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academies Press; 2001.
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10. American Diabetes Association. Diabetes Basics. Type 2. http://www.diabetes.org/type-2-diabetes.jsp.
11. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure - Complete Report. http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm
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13. Aspinall S, et al. Medication errors in older adults: a review of recent publications. Am J Geriatric Pharmacother. 2007;5(1):75-84.
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