“Minding Our Meds” Demonstrating Senior Medication Adherence with Cell Phone Texting Reminders
Front Porch Center for Technology Innovation and Wellbeing
The “Minding our Meds” program addresses medication adherence among active, independent older adults in need of a mobile solution utilizing a medication mHealth SMS Texting program. The elements of this innovation include a two-way SMS messaging service (CareSpeak) and a programmable website dashboard that customizes alerts according to medication name, day and time of the alert, dosage, and refills. The CareSpeak dashboard provides adherence feedback that charts compliance information based on a user’s response to the alerts. The program engaged 105 older adults from senior living communities and other community organizations over a 3-5 month period. While average responses to self-reported medication adherence questions improved between baseline and follow-up, the changes were not statistically significant. Self-reported satisfaction measures among participants at follow-up were positive, reporting that the program made it easier to keep track of medications (n=57/86, 66%).
Participants provided valuable insight into the usefulness of the intervention and the challenges they faced in both the follow-up survey and during focus groups. Age, cognitive ability, and technology comfort levels are all important factors that shape an individual’s experience with the medication adherence program. The findings of this initiative indicate that a cell texting reminder program is a viable and affordable solution for medication adherence for older adults. Findings also indicate that the program is not a ready-made fit for all older adults. The medication adherence texting program will likely be more successful if it has an intervention length of 10-15 weeks, and targets a specific population of seniors in need of a medication management solution who are independent, younger, experiencing very mild memory loss, and have a baseline comfort level with technology.
The SMS text messaging program for medication reminders continues to be used at Front Porch. Given its relatively low cost, sustained use is being funded as part of usual care in Front Porch communities.
WHO WAS INVOLVED
CareSpeak Communications, Front Porch (Sunny View, Villa Gardens, Kingsley Manor, Claremont Manor, Walnut Village, Carlsbad by the Sea, Fredericka Manor), community-based organizations (Angelus Plaza, Little Tokyo Service Center, All Peoples Community Center, Erasto R. Batongmalaque Foundation), One Economy Corporation, Sprint Nextel, University of California, San Francisco (evaluation and program design), Front Porch Center for Technology Innovation and Wellbeing
WHAT THEY DID
The likelihood that an older adult takes prescription medication is high: 91% of individuals aged 57-85 take at least one medication and at least 30% require five medications to be taken daily or weekly.
- The average older person takes 4.5 prescription medications and two over-the-counter drugs.
- The average person aged 65 to 69 fills 13.6 prescriptions per year; those aged 80-84 fill 18.2 prescriptions per year.
Many of these medications are administered to address chronic disease, including hypertension, diabetes, congestive heart failure, depression, and arthritis.
The magnitude of medication non-adherence is enormous: unnecessary illnesses, disabilities, and premature deaths due to improper medication management amount to estimated healthcare costs of $290 billion per year according to a 2009 study. The reduced cognitive and memory capacity of older adults as they age tend to lead to an increasing problem with the functional ability to remember to take one’s medication. The most commonly cited reason for not appropriately adhering to medication intake among older adults is forgetfulness.
Recent research supports the efficacy of SMS-based texting to help remind individuals to take their medications. These studies have focused on the use of cell phone texts to help patients with prescriptions for organ transplant, hypertensive and asthmatic patients. However, there is very little research on texting and medication adherence among the older adult population.
The program participants included 105 older adults at least 50 years of age; residing in independent living settings in California; not participating in a medication management program or service; taking at least one regular daily medication (prescription or OTC), vitamin, or dietary supplement; and with no hearing, vision, or other physical abilities that could interfere with the operation of a cell phone.
Description of the Program:
The Minding our Meds program enrolled 105 participants over 10 locations throughout California. Participants were divided into three cohorts: Cohorts 1 and 3 participated in the program for 3 months, while Cohort 2 participated for 5 months to test for sustainability. The project involved four implementation components that included Recruitment, Training, Adoption and Technical Support, and Feedback.
Recruitment. FPCTIW staff initiated outreach activities to Front Porch and community based organization directors, and arranged for presentations to community members and residents. These presentations were then followed up with interest sign-up sheets and special invitation letters sent to potential participants on behalf of the community staff.
Training. Interested program participants were invited to attend a workshop that provided a detailed overview of the innovation and participation requirements, the completion of intake forms and surveys, and basic cell phone/texting training. These workshops included help from student volunteers to provide instructions on cell phone operations.
Adoption and Technical Support. One week following the initial training and in subsequent monthly intervals, FPCTIW staff and volunteers conducted status calls to check in on the user to address any issues or concerns. Technical questions were handled over the phone, or if necessary, through a visit to the participant’s home. Individuals were regularly monitored for adherence on the CareSpeak dashboard based on text confirmation responses. These calls were conducted by both staff and volunteers.
Feedback. At the conclusion of each cohort’s participation in the Minding our Meds program, participant focus groups and individual interviews were conducted to collect anecdotal and more in-depth responses to the program. Each participant completed a post-assessment survey.
Enrollment/selection criteria and process:
- Over 400 individuals throughout California were invited to participate in the project. The recruitment efforts included group and community presentations, special invitations from residential community staff members, and personal outreach.
- Criteria to participate include:
- Independent living residents
- Currently not involved in a medication management program or service
- Hearing, vision, and other physical abilities that did not interfere with the operation of a cell phone
- At least 50 years of age
- Taking at least one regular daily medication (prescription or OTC), vitamin, or dietary supplement
- A total of 105 participants enrolled in the program from over 10 facilities. Seventeen participants dropped out of the program, an attrition rate of 16%.
- Participants recruited from one senior living community, Claremont Manor, had a higher attrition rate than other recruitment sites (6/17, 40%).
- Forty-two percent (42% of participants used their own cell phone during the program (37/88) while the balance of the participants used a cell phone provided by FPCTIW.
- Of the 17 participants who dropped out of the program, 16 were not using their own cell phone. The attrition rate was only 2.6% for those using their own cell phone (n=38) compared to an attrition rate of 24% for those not using their own cell phone.
Researchers used a quasi-experimental design to examine older adults’ medication adherence pre- and post- intervention. A mixed-methods approach was taken, with both quantitative and qualitative data collected through pre- and post-survey instruments and focus groups. The researchers consulted with project partners during data collection and analysis to help inform the interpretation of the findings.
- A total of 105 participants were enrolled in the program. 15 (17%) participants were enrolled in Cohort 1, 35 (40%) in Cohort 2, and 38 (43%) in Cohort 3.
- Participants were recruited from over 10 senior living communities. A majority of participants were recruited from four senior living communities: Angelus Plaza (n=16, 18%), ERB Foundation (aka Argent) (n=15, 17%), Claremont Manor (n=9, 10%), and Walnut Village (n=9, 10%).
- The average age of participants was 76.42 years old.
- 73% of participants were women (64 vs. 24 men).
Increased Belief in Medication Adherence Improvement. Self-reported measures of medication adherence showed slight improvement from baseline to follow-up. The number of participants reporting that they forget to take their medicine decreased from 50 to 44. The number of participants reporting that they are careless at times about taking their medicine declined from 31 to 25. While 17 participants reported at baseline that they sometimes stop taking their medication when they feel better, only 10 reported the same at follow-up. Similarly, 20 participants at baseline indicated that they stop taking their medicine if they feel worse when they take it while only 13 participants reported the same after the intervention.
Based on participant text message response to their reminder(s), the average adherence rate reported by CareSpeak dashboard for all respondents was 40% (n=105), which is similar to other reported texting program adherence rates (average of 30%). However, focus group responses indicated that the response rate was higher in that many patients who had low adherence rates based on the CareSpeak system reported that their responses to the alerts had not registered. Some participants reported that they found the alerts helpful to managing their medication, but didn’t bother to respond. Thus, the measurement of medication adherence through the CareSpeak dashboard likely under reported compliance.
Though not significant at p<.0025, participants who used their own cell phone had a higher average adherence rate (M=58%) than those who did not (M=39%) (n=86, SD=34.9, p=.009). This trend suggests that ownership of and familiarity with one’s cell phone needs to be considered as a factor in successful use of a medication adherence texting program.
Positive Patient Satisfaction, Especially Among Certain Demographics.
- Most participants either agreed or strongly agreed that CareSpeak made it easier to keep track of their medications (n=57/86, 66%).
- About half of participants either agreed or strongly agreed that their health issues were better controlled at follow-up than just before the program (42/88, 48%).
- Over half of participants either agreed or strongly agreed that they would use CareSpeak or a similar program in the future (46/88, 52%).
- All measures of participant satisfaction were highest among participants who had the shortest intervention period (10-15 weeks) (p<.000). Reported satisfaction with the intervention slowly declined as the intervention period increased.
- Participants between the ages of 50-74 were more likely than those 75-84 to agree that they would use CareSpeak, or a similar program, in the future (p=.001).
Behavior Change Reported in Medication Management Habits. Participants reported that CareSpeak helped them create a schedule or a habit of taking their medication that they would benefit from even if they didn’t continue to use the service.
- No comparison group was used and participants were selected based on need for assistance with medication adherence or otherwise recommended by facility staff.
- The intervention length varied as a result of scheduling issues.
- Trainings and support were provided in English, Korean and Spanish and, where possible, participants translated for other participants. However, these results should not be generalized to non-English speaking populations.
HOW THEY DID IT
Context of the Innovative Program:
“Minding Our Meds” is managed by the Front Porch Center for Technology Innovation and Wellbeing, a 501(c) (3) nonprofit based in Burbank, CA that explores innovative uses of technology to empower individuals to live well, especially in their later years. Though FPCTIW is an independent agency, it works closely with the Front Porch family of senior living and affordable housing communities representing over 5,000 residents throughout California. FPCTIW also partners with a number of other community-based organizations that include senior service centers, community clinics, health plan organizations, research institutions, and technology companies.
A key component to supporting the implementation of the program was a telecommunication program called the Western States Contracting Alliance (WSCA), which provides bulk government and nonprofit purchasing contracts for telecommunication products and services. As a member of the WSCA and partner to the initiative, Sprint was able to provide over 100 free handsets, signal boosters, and highly discounted text and voice rates.
CareSpeak’s contribution to “Minding our Meds” is part of the company’s larger effort to deploy a medication adherence texting solution to patients. The company’s Mobile Medication Manager provides customized texting services for medication alerts, diabetes reminders and tracking, and wellness/education programs. CareSpeak is currently targeting or contracting with health sector industries that include pharmaceutical companies, health plans, pharmacy benefit managers and employers, and hospitals and integrated delivery networks.
Planning and Development Process:
Much effort was placed in the planning and recruitment preparation of the project. Key to pre-implementation was the development of outreach and educational content to communicate and summarize the project goals and objectives to potential participants, and presentations made to the communities based on that content.
The project included a 3-part video series, “Minding our Meds: Demonstrating Senior Medication Adherence with Cell Phone Texting Reminders”, that was composed of an overview of medication adherence and older adults (“Why It’s Important to Take our Meds”), a summary of the innovation (“The CareSpeak Mobile Medication Manager”), and a tutorial “Using CareSpeak’s Mobile Medication Manager”). All the videos were scripted, developed, and produced by FPCTIW in collaboration with One Economy, and can be found at CTA’s Website.
Program outreach commenced with a presentation to 400 staff of Front Porch communities, which was later followed up with individual communications with the executive directors and their activities directors, nursing staff, and administrators.
Recruitment was also conducted through outreach to non-Front Porch organizations providing services to the older adult population. FPCTIW also utilized volunteers, primarily students, in the recruitment process. College and graduate students from local universities underwent mandatory volunteer orientations that included HIPAA training and background screenings. These students helped fulfill important training and adoption resources necessary during participant workshops that included cell phone instruction and enrollment in the program.
The project plan also included regular and follow-up status calls that were conducted by staff and volunteers who contacted participants based on a simple questionnaire. These calls were made one week after the initial training, and followed up monthly thereafter to identify any problems or technical support needs.
Finally, key to planning and development included the involvement and participation of an evaluator/researcher from UC San Francisco who helped structure the project, co-developing survey tools, focus group questions, and cohort parameters to maintain consistency and form throughout the evaluation process.
ADOPTION CONSIDERATIONS AND LESSONS LEARNED
Getting Started with This Innovation: FPCTIW gained important and critical lessons from this project. Three important project pre-requisites include:
- Vendor screening and back-up vendor solution. Given the current volatility of the technology sector seeking to make inroads into ehealth and telehealth services, it is important to select a vendor that can demonstrate some relative stability and a track record. This planning activity should be conducted early in the establishment of a program and must include reviews and discussions of the company’s finances and history with other customer organizations. It is important to have an alternative vendor solution in place. The final vendor ultimately provided a stable and reliable solution, and proved to be responsive to the needs of the program.
- Messaging and recruitment. A critical component to recruiting patients for a technology-based program must begin with an understanding of the population the project is targeting. Inclusionary guidelines should be settled at the outset, and need to consider age-related abilities and other factors in the adoption of the proposed solution (i.e., low vision/hearing, arthritis). Messaging needs to be carefully crafted to emphasize the potential benefits of the solution, how it could help meet the needs of the target population, and how their participation will contribute to a greater understanding of the solution’s viability applied to a larger population of older adults.
- Design technology adoption strategies. Follow-up and follow-through strategies must include a rigorous and clear plan to address technical support issues with participants. Whether the plan includes monthly telephone status calls or onsite technical assistance, program staff need to outline an approach that will both pre-empt adoption challenges and appropriately address concerns on a case-by-case basis. An important component of this approach is to also make adoption tools ready and available; these may be in the form of a cheatsheet handout or a website link referencing support for the innovation.
Sustaining and Scaling Use of the Technology: As discussed, preliminary findings indicate that a SMS texting solution is most effective with a particular segment of the older adult population. FPCTIW is focusing program diffusion efforts to a targeted group of older adults as opposed to wide scale adoption across their entire older adult population. Medication management through SMS texting will be a value added offering provided on an as needed basis. The program is anticipated to grow overtime as the smart phone adoption rate increases with older adults.
Given its low cost and the way it fits into an existing staff and service model, no significant additional funds are needed to add this service as one of many options to help older adults live well.
Significant Interest in mHealth Medication Management Solutions. The large turnouts for recruitment meetings (over 400 seniors), the significant attention the program received in Front Porch communities, and the engagement and dialogue that ensued regarding the challenges and opportunities for improved medication management solutions reaffirmed that this is an important program that can impact an older adult’s quality of life.
Target Subset of Older Adults that Will Benefit the Most from a SMS mHealth Medication Management Solution. The program identified characteristics of a subset of older adults that benefited the most from this program to include individuals who are between the ages of 50-74, have cell phone experience or possess their own cell phones, and are minimally impacted by cognitive or physical dexterity issues. When implementing such a program, older adults should be comfortable using their phones to send and receive text messages, carry their phones with them at all times, and be able to update their alerts online. Significant training is necessary if they are not comfortable in any of these areas. Older adult technology adoption is significantly impacted by cognitive abilities and physical dexterity and capacities.
Find Ideal Intervention Length. The inherent characteristics of repetitive reminders, coupled with the number of reminders received a day over the length of the intervention, must be balanced to determine an effective intervention outcome. All measures of participant satisfaction were highest among participants who had the shortest intervention period (10-15 weeks) (p<.000). Reported satisfaction with the intervention slowly declined as the intervention period increased. Some participants enthusiastically embraced the innovation, but indicated during focus group meetings irritation with prolonged regular texting reminders.
Texting Response not Necessarily Indicative of Medication Adherence. Results indicate that texting responsiveness among participants is not necessarily indicative of medication adherence in that many users hear the alert to take their medication, do so, and do not reply they have done so via text.