Improving Medication Management Practices and Care Transitions through Technology

The home health care industry is comprised of over 10,000 Medicare-certified home health agencies (HHAs) that provide post-acute and long-term care services to a heterogeneous population. Home health patients, who are disproportionately female and elderly, are clinically diverse and especially vulnerable by virtue of their advanced age, multiple co-morbid conditions, and functional dependencies. Skilled nursing care is the core service provided by HHAs, which conducted more than 121 million home health visits with Medicare beneficiaries in 2008.

This project examined the relative effectiveness and cost-effectiveness of a health information technology (IT) intervention designed to facilitate high-quality care transitions to home health care. The project developed a medication management system intended to improve clinician practice by providing clinical decision support (CDS) and to enhance patient engagement by providing supplementary information to patients with complex medication regimens. The study took place at a large, urban, non-profit home health care organization in the New York City region.

The specific aims of this project were to:

• Examine the relative effect of the intervention on workflow and medication management practices of home health care nurses. 
• Examine the relative effect of the intervention on the outcomes and service use of patients in the respective study groups. 
• Estimate the costs associated with the intervention and subsequent care and compare these costs relative to usual care. 

The project used a randomized trial to evaluate the effectiveness of the IT intervention to improve medication management for patients with complex medication regimens. The intervention tested an automated algorithm that identified high-risk patients and sent an email alert to the home health nurse shortly after the patient’s admission to home care. It also provided the nurse with medication decisionmaking support, including high-risk medication management recommendations that were integrated into the clinician’s visit documentation system and the patient’s electronic health record. The system was evaluated by comparing the intervention to a usual care group. Five hundred nurses were enrolled in the study, with 33 percent randomized to the intervention arm. A total of 7,919 patients were also enrolled, with 32 percent in the intervention arm.

A survey was administered to a subset of 826 participants. The results did not show improvements in the process of care, patient knowledge of medications, or patient medication management. However, within the intervention group, nurses’ use of CDS was associated with significantly more patients moving below the medication complexity risk threshold and lower patient hospitalization rates.

Use of the CDS by nurses was variable, likely due in part to variations in the nurses’ level of comfort with the different care management practices embedded in the CDS tool or with variations in their comfort with the IT system itself. The more patients a nurse had in the study, the more likely the nurse was to use the tool. Several patient characteristics also predicted CDS use by the nurse. The CDS was more likely to be used among patients with a longer length of home care service and more nurse visits. Nurses used the tool more often with patients who took a greater number of medications. This study provides new information on the predictors of CDS use and the impact of CDS use on patient outcomes in this population. Strategies to increase use of CDS tools need further exploration to provide greater benefit to more patients.