Delivering Culturally Appropriate Care to Optimize Medication Use in the Elderly

Connecticut Pharmacists Foundation

Project Description:

Connecticut Pharmacists Foundation (CPF) implemented a culturally and linguistically appropriate Medication Therapy Management (MTM) program for older Cambodian-Americans to improve medication-related problems using video conferencing technology. Services were provided collaboratively through the Connecticut Pharmacists Foundation, Khmer Health Advocates, and Mount Carmel Cambodian Project, and delivered by pharmacists and community health workers (CHWs) trained to use telemedicine in Long Beach, California (CA), Connecticut (CT), and Western Massachusetts (MA). Pharmacists in Connecticut communicated through high-definition video with CHWs and patients in Long Beach, California. A software program (Assurance©) for pharmacist MTM documentation and an electronic medical record with spoken format technology (CIMS©) for surveys administration, developed by Khmer Health Advocates (KHA) were also used for all patients.

The older Cambodian American community has exceedingly poor health when compared to both the general and Asian American population (RAND 2010 study). In this initiative, the average number of medications and conditions per patient was 10.3 and 6.6, respectively. The most common conditions were cardiovascular disease, pain, diabetes, and depression/PTSD; and the most common drug categories were consistent for these conditions. Patient conditions did not differ significantly between the two sites.

The goals of the project were to:

  • Successfully diffuse the medication management program utilizing PMD machines to four different provider types in four new geographic locations in California.
  • Improve patients’ drug therapy outcomes >20% from baseline.
  • Demonstrate similar improvement of drug therapy outcomes between face-to-face and telemedicine-provided service.
  • Reduce potentially inappropriate medication use >20%.
  • Demonstrate a reduction in health expenditures compared to the cost of providing the service by a factor of least 8 to 1.

Approach:

Over a 6-9 month period, pharmacists and CHWs met face-to-face with patients in CT/MA, while CA patients met in person with a CHW while the pharmacist participated via high-definition video conference link. Patient criteria included participants age 60 and over, the presence of at least one chronic condition and three chronic medications. A total of 627 patients were screened (282 in CT/MA, 345 in CA). CT/MA enrolled 53 patients with 147 total encounters (2.8/patient) and CA enrolled 43 patients with 70 total encounters (1.6/patient) with the goal of conducting 4 encounters per patient over a 12 month period. Prior to and during the initial encounter, the pharmacist and CHW compiled a comprehensive medication profile, including prescription, non-prescription and traditional therapies. At the time of patient enrollment, a medical record was requested from their primary care provider (if available). At all encounters the pharmacist assessed each medication for appropriateness, efficacy, safety, and adherence (in this sequence) to achieve optimal therapy goals. Pharmacists also assessed the patient for determinants of health — physical characteristics, socioeconomic status, education level, psychological factors and behavior that could impact medication use and overall health. At the end of all encounters, the pharmacists provided patients with a Personal Medication Summary report that included a comprehensive medication list and a patient action plan. The pharmacists also sent an electronic copy of the MTM Summary Report to the patients’ primary care provider; this included the comprehensive medication list, description of medication related problems, and treatment recommendations.

Results:

This initiative demonstrates that pharmacists, when working with Community Health Workers to provide MTM using video conferencing, can improve patient medication outcomes and reduce total health care costs. The application of culturally and linguistically appropriate technologies for the provision of MTM decreases medication related problems for high risk, isolated patient populations.

Significant Number of Medication Related Problems Identified and Solved. A total of 604 medication related problems (MRPs) were identified (6.3/patient), and nearly all (93%) were resolved during the project period. The majority of MRPs (81%) were attributed to problems with medication indication, effectiveness, and safety, while adherence problems accounted for 19% of MRPs.

Increase in Patients Achieving Their Therapy Goals. Overall, the percentage of patients’ therapy goals achieved increased from 69% to 93% after MTM services were provided. There was significant improvement in depression screening (p=0.022), in adherence behavior (23% increase from the first to final visit, p=0.027), and of inappropriate medication use (34.5% reduction) from initial to final encounter.

Virtual Medication Therapy Management (MTM) as Effective as Face-to-Face MTM. Health improvements were similar between the CA virtual MTM and CT/MA Face-to-Face MTM groups (p<.05), which suggests that face-to-face and telehealth culturally appropriate MTM consultations were equally effective.

Return on Investment Between 4.8:1 and 6:1. Total health avoidance costs (for the time period) were $291,114 ($3032/patient/year), and exceeded the cost of providing the service by a factor between 4.8:1 and 6:1. Actual utilization costs could not be obtained; however, cost avoidance was estimated using evidence-based analytics from Assurance© software. The costs of providing MTM services was calculated by adding pharmacist and CHW service claims for each patient, and comparing these costs with the total of direct cost savings (drug changes or drug prevention costs) and evidence-based estimated cost avoidance (health care costs and prevention savings).

Sustainability:

Culturally appropriate MTM has been integrated into KHA treatment programs for in-person visits in CT and has been established as a core component of the national Cambodian medical home model.

Lessons Learned:

Test Broadband and Wireless Connectivity of Geographical Region. CPF and its partners encountered inconsistent broadband and wireless availability and challenges in operating a teleheath project across multiple time zones. Inconsistent broadband speed led to inconsistent video and sound quality with just over 80% of videoconferencing visits proving successful. Video conferencing tended to be more successful if the home had wired internet, but less successful with wireless connection. The outcome of these technology barriers decreased the total number of visits scheduled for CA patients, either through cancellation, delays, or switching to phone-only sessions.

Community Health Workers Improve Patient-Provider Communication. Language barriers often challenge the formal health care professional-patient relationship. Utilizing CHWs that are fluent in the patients’ primary language can help with technology assistance, access to screening services, and provision of medical interpretation, allowing for a smooth conduit of information between the health care professional and the patient or informal caregiver. The CHW also provides an excellent mechanism to assist the patient with following through on pharmacist recommendations.

Address Cultural Needs to Further Patient Engagement. Cross-cultural preparation time is needed to understand specific idiosyncrasies of the community, which allows for faster uptake of both the technology intervention and health management education. For example, the project found Cambodian patients tended to say “yes,” so as to not offend the provider, even when they did not fully understand the question or issue.

Review Video Conferencing Logistics for Patients and Providers. Pharmacists and CHWs experienced a steep learning curve on the effective use of video conferencing technology and the importance of the physical set up. Successful interactions depended on optimal lighting, positioning of the camera (built in laptop cameras above the screen proved easier to use as eye contact could be maintained when looking directly at the screen), position of the medication bottles, as well as lining up backup systems if the video conferencing system malfunctions.

Pharmacists Recognition as Health Care Provider for Medicare Reimbursement Needed. Medicare does not recognize pharmacists as health care providers, significantly impacting payment for Medication Management Therapy.

Streamline Provider Licensure Across State Lines for Telehealth Use. A challenge for widespread adoption of the CPF model of care relates to licensure and regulatory issues. Providing medical care across state lines via video conferencing is at odds with the current requirement that health care professionals be licensed in the state in which they practice. If a physician, for example, electronically interacts with patients that are located in other states, they must generally(1) be licensed or registered in each state. To ease the challenge of state licensure, particularly for cross-state teleconsultations, states have the authority to create an interstate compact. The Nurse Licensure Compact is an example of a multi-state compact that eases the barriers to establishing multiple licenses across state lines. The compact allows a nurse to have one license (in his or her state of residency) and to practice in other states (both physical and electronic), subject to each state’s practice law and regulation. States can also license by endorsement, meaning health professionals licensed in other states that have equivalent standards may be granted licenses. For example, Idaho utilizes licensure by endorsement for physicians that have licenses in states that have standards that are similar to Idaho’s licensing standards. States may also establish reciprocity agreements for health care professionals.


1 Licensure exceptions may apply during an emergency or natural disaster, or to specific physician groups, such as medical residents or military physicians.