Complex medication regimens create challenges for home healthcare

NYU study identifies gaps, opportunities for medication management coordination between providers

Medically high-risk patients and communication breakdowns between providers contribute to the difficulty of medication management for older adults receiving home health care, finds a study led by researchers at NYU Rory Meyers College of Nursing. The findings are published in the journal Medical Care Research and Review.

“Our study suggests that medication management coordinated from home care has the potential to improve medication safety for older adults and reduce the risk for initial hospitalization and readmission to hospitals,” said Allison Squires, PhD, RN, FAAN, associate professor at NYU Rory Meyers College of Nursing and the study’s lead author.

Older adults are more likely to be taking multiple medications, creating complex drug regimens. These regimens vary in complexity based on the number of medications, the dosages and frequencies of those medications, and any special instructions related to taking them as ordered. Increased medication complexity can impair patients’ abilities to take their medications as directed and raises their risk for hospital admission, readmission, and adverse events.

Home health agencies provide person-centered care for patients in their homes, often through the use of interdisciplinary clinical teams of nurses, physical therapists, occupational therapists, speech therapists, home health aides, and social workers. Medication management is a primary service provided by home care.

This study sought to understand medication management challenges from the home care provider perspective. The researchers conducted interviews with 77 home health care professionals, including nurse practitioners, nurses training to become nurse practitioners and midwives, social workers, social work students, pharmacists, and pharmacy students.

The researchers identified two key themes in their interviews: a “fragmented system of care” and “vulnerable patients in vulnerable situations,” with patient-, provider-, and system-level factors contributing to both communication and coordination challenges.

The “fragmented system of care” highlighted through the interviews involves communication breakdowns between health care providers—including between multiple home health providers and between home health and office-based providers—and between providers and patients. This breakdown of information due to patient-level factors (e.g., lack of trust with providers), provider-level factors (e.g., inadequate provider-provider communication or lack of relationship between home health and office-based providers), and system-level factors (e.g., lack of time with patients, electronic medical records not being available across providers) creates opportunities for medication errors.

In describing “vulnerable patients in vulnerable situations,” home health providers shared how many older adults in home care are both high-risk, or medically complex, and in high-risk situations, as most live alone. These risks were described as a complex interplay of patient-level factors (e.g., living alone, language barriers, or cognitive issues), provider-level factors (e.g., not giving clear instructions for taking medication), and system-level factors (e.g., clinical turnover, lack of resources) that affected patients’ medication complexity and their ability to take medications safely.

Participants also described medication errors they observed. A patient taking the wrong drug was the most common error reported (54.5 percent), followed by a patient taking the wrong dose (31.8 percent) and taking a drug at the wrong time (13.6 percent).

Medication safety issues along with provider-provider communication problems were central themes with medication complexity, and fragmented care coordination contributed to this complexity. As such, the researchers note that medication management coordinated by home care providers has the potential to improve medication safety for older adults, which in turn would reduce their risk for hospitalization and readmission.

“Allowing nurse practitioners in home care to conduct medication coordination with a patient’s physicians has the potential to address the issues with fragmented care coordination and may save costs. Even better would be a coordinated effort between interdisciplinary home care teams, including nurse practitioners, social workers, and pharmacists,” said Squires.

In addition to Squires, study authors include Laura Ridge, Sarah Miner, Sherry A. Greenberg, and Tara Cortes of NYU Meyers and Margaret V. McDonald of the Center for Home Care Policy & Research at the Visiting Nurse Service of New York. The study was funded by the Nursing Education, Practice, Quality, and Retention (NEPQR) program funded through the Division of Nursing, Bureau of Health Workforce, Health Resources, and Services Administration (HRSA) of the Department of Health and Human Services (HHS) (grant # UD7HP26049).