10/31/2014. Medication Adherence: Development of an EMR tool to monitor oral medication compliance. Conflict of Interest Disclosures.

Transcription

1 Medication Adherence: Development of an EMR tool to monitor oral medication compliance Donna Williams, RN PHN Carol Bell, NP MSN Andrea Linder, RN MS CCRC Clinical Research Nurses Stanford University SOM NOVEMBER Conflict of Interest Disclosures Andrea Linder: Incyte Nursing Education Promotional Speaker Program, Novartis Nursing Advisory Board Donna Williams: Lexicon Pharmaceuticals Nurse Advisory Council, Ipsen Pharmaceuticals Nurse Advisory council. Objectives Identify two barriers to medication adherence Understand the utility of a tool to ensure that quality measures are being documented consistently within the EMR. Identify opportunities in their own practice settings to implement a tool in the EMR that will meet their needs Identify stakeholders within your institution that will collaborate in order to institute best practices across practice setting. 1

2 What? Oral Medication Nonadherence Drug s don t work in Patients who don t take them -C. Everett Coop. Unites States Surgeon general This also holds true in patients that don t take them correctly. Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost Medication non adherence is prevalent among patients and is associated with adverse outcomes. 1 Medication non adherence is prevalent among patients with diabetes mellitus, CHF, Hyperlipidema. 1 Interventions are needed to increase medication adherence so that patients can realize the full benefit of prescribed therapies. 1 Attention should be directed to education and check in with patients on medication adherence which would lead to better outcomes for patients. High adherence to medications correlates with lower disease related medical costs. 2 2

3 For many medical conditions. there is strong evidence that prescription drugs provide clinical value. Adherence with medication therapy is generally low (50-65% on average). 3 Symptoms and complications arise when conditions are treated suboptimally. This leads to ER and hospitalizations. Studies suggest that if adherence to medications drop as a result of benefit plan changes, medical utilization for some conditions may increase and these costs often exceed drug costs. Oral Oncolytics Within the oncology pipeline there is a shift from infused or injectable to oral medications. Currently 30% of the oncology pipeline consists of oral agents. 4 In 2012, 73% of the oncology agents approved were oral therapies. 4 Who will take ownership for management of outpatient chemotherapies? Increasing need for RN s to address education and monitoring to ensure quality of care. Considerations Oral Adherence Baseline assessment: -physical condition -cognitive ability -communication -support network -financial status -drug acquisition options Barriers to Adherence include: Visual, physical, cognitive impairments Lack of social or family support Financial issues Toxicities, Side effects Lack of understanding of chronic treatment or consequences of noncompliance. 3

4 Who? Stakeholders Staff Roles for the Oncology Team Proactive Team Focused Approach Physicians Pharmacists Epic/Beacon Plan developer Clinic & Nurses Infusion Treatment Nurses Education Staff education Patient and family Communication Discussion of treatment options. Communicate family, pharmacy, PCP Follow up Measure quality outcomes Clinicians/Providers Patient selection Treatment plan development Routine monitoring Symptom management Education Documentation Communication Consent 4

5 Patient & Caregiver Consent to Treatment Identification of symptoms Symptom Management Determing QoL Education Adherence to regimen Administrative Services Reimbursement Accredo (no copay assist) Caremark (CVS) ACS Patient Assistance Triage Why? Quality Assurance, Implementation of National Guidelines 5

6 Quality Assurance Outcomes Process Outcomes Management Adherence Development of Standards ASCO/ ONS Chemotherapy Safety Standards Updated 2013 For oral chemotherapy, the frequency of office visits and monitoring that is appropriate for the individual and the anti neoplastic agent is defined in the treatment plan Before initiation of an oral chemotherapy regimen, assessment of the patent s ability to obtain the drug and administer it according the treatment plan is documented as well as a plan to address any issues. o Financial assistance programs o Specialty pharmacy Assessment includes socioeconomic, psychosocial, financial, administrative and or regulatory factors that may influence initiation or adherence. How? Documentation and Follow-up 6

7 Develop a patient education plan Tools for patient education / adherence Techniques for self monitoring (pill containers, counts) Treatment calendar Motivational interviewing (compared with traditional counselling) Readiness to change scale Implementation of Standards Treatment visit recommendations: Define standard regimens by diagnosis with references readily available For orders that vary, provide a supporting reference with dose modification guidelines Clinical Visit recommendations: Assess and document clinical status including performance status. Verify Allergies, previous reactions, treatment toxicities, dose reductions. Assess for psychosocial need for support EMR as the Tool 7

8 Process development: How to refer to specialty pharmacies which carry oral oncolytics Specialty Pharmacy order forms, assure that patients understand how to take, who to call for questions, what to do if they miss a dose. Advantage of specialty pharmacy is that they will put in blister pack for patients that have neuropathies (Xeloda) or difficulty opening bottles. 8

9 Documentation in the EMR with ASCO / ONS Standards Strategies to overcome barriers must be developed at initiation of oral agent to accomplish treatment goals Nursing education Patient Advocate Identify any barriers to medication adherence Review orders on specific medication Monitoring guidelines including assessment of toxicity and symptom management Determine schedule for follow-up and monitoring Telephone follow-up schedule How can nurses influence the care model? Educate themselves, colleagues and patients Collaborate in development of standards and practices. Integrate into clinical notations Evaluate patient risk and treatment variables Nursing Applications: The Clinical Research Nurse as Educator Personalized Medicine is driven by technology. Clinical research nurses must: Understand oral oncolytics, side effects and management Oral Chemotherapy is a relatively new treatment option, policies are under development 2013 ASCO/ONS have published standards for chemotherapy administration and were expanded to include oral chemotherapy 9

10 Nursing Applications: The Clinical Research Nurse as Educator Provide guidance and integrate clinical standards for evolving technology and treatments Explain how targeted therapies work in signaling pathways Patient education when safely administering these therapies and monitoring for toxicities Review and evaluate reports for biomarkers, incorporating molecular level reports in patient assessments Assist with collection of samples appropriate for testing Benefits of Educating patients and families Identifying the issue to be studied Helping inform clinical trials Converting information into a useable form. Identifying appropriate methods of dissemination. Facilitating buy-in. Providing insight and understanding of contextual issues that impact research. Summary Medication non-adherence prevalent among patients Compliance associated with lower disease related cost Collaboration with hospital resource team members Nurses as key educators EMR as tool for compliance Need to develop policies to standardize ONS / ASCO guidelines Assess barriers for medication non-adherence 10

11 References 1. Ho, M.P., Rumsfeld J.S. et al, Effect of Medication non adherence on hospitalization and mortality among patients with diabetes JAMA Sept 2006 Vol 166, No 17 pp 2. Sokol, M. C., McGuican, A., Verbrugge, R. R, Epstein, R. S., Impact of Medication adherence on hospitalization risk and healthcare cost, Medical Care Vol 3, No Lippincott and Williams pp CMS National Healthcare Expenditures Projections : Association of Community Cancer Centers. Dispensing pharmacy: an option for private practices. Association of Community Cancer website. Pharmacy.overview.asp Accessed sept Aisner, 2007, Lie, Franssen, Fitch & Warner, 1997 (For Slide #13) 6. Neuss, McNiff,Oncology Nursing Forum, Volume 40, #3. May 2013 pg Matthew, J. Caprera, P. Essentials of Oral Oncolytics..Developing a Nursing Reference. October 2014 v 18 no 5. Clinical Journal of Oncology Nursing. 11