SLPs play an important role in home health medication education

Here’s the outline of this post:

• Adverse drug events are a serious problem:
  • Many people are injured by adverse drug events.
  • Adverse drug events are expensive.
  • Many adverse drug events are preventable.
• Why home health agencies are focused on medication education.
• SLP scope of practice and scope of license.
• General approaches to reducing adverse drug events.
  • Encourage patients to be more active in their own medical care.
  • Use technology to reduce adverse drug events.
  • Improve and standardize labeling and packaging of medicines.
• 9 ways home health clinicians can help.
• A deeper dive into the SLP’s role.
  • Identify and address communication, cognitive, and physical barriers.
  • Use resources to assist our patients to understand their medication.
  • Develop and teach strategies to improve adherence to medication routines.
• 31 strategies to improve adherence.
• My final thoughts.
• References

Adverse drug events are a serious problem

An adverse drug event (ADE) is an injury caused by errors taking medication, side-effects, or allergic reactions. ADEs harm many people every year and are very costly. Many adverse drug events are preventable. Below are just a few statistics.

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Many people are injured by adverse drug events

It’s challenging and controversial to estimate deaths caused by ADEs. However, here are some statistics to show how big a problem it appears to be:

• Over a million people visit the emergency department each year due to medication errors or side-effects.
• More than one in four of these people have to be hospitalized for further treatment.
• ADEs account for 30% of hospitalizations of older adults.
• Thousands of people die each year in the US due to ADEs according to the FDA’s MedWatch.

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Adverse drug events are expensive

The Institute of Medicine of the National Academies (IOM) published a report in 2006 which includes statistics on estimated costs of adverse drug events:

• Each preventable ADE that occurs in a hospital costs an additional $8,750.
• ADEs that occur in the community cost $1 billion dollars each year.
• Preventable ADEs in Medicare recipients (65 and older) costs $887 million per year.
• 3 million older adults are living in nursing homes due to difficulty managing medication, costing $14 billion dollars yearly.

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Many adverse drug events are preventable

The 2016 IOM report states that:

• 1.5 million avoidable ADEs occur every year, mostly in hospitals and long-term care facilities.
• More than 530,000 avoidable ADEs occur in community-based Medicare recipients.

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Why home health agencies are focused on medication education

In addition to being motivated to provide high-quality care to patients, as of January 2018, home health agencies are now legally obligated to provide medication education to all patients. (Loehr & Malone, 2018)

In fact, CMS has incentivized participation by establishing penalties for re-hospitalization and increased reimbursement for favorable STAR ratings and patient satisfaction surveys. (Loehr & Malone, 2018)

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SLP scope of practice and scope of license

ASHA’s Code of Ethics for SLPs includes the following:

• As SLPs, we’ll only provide services that we’re competent to perform.
• We shall use “every resource, including … interprofessional collaboration when appropriate, to ensure that we deliver quality service.

ASHA’s Scope of Practice for SLPs includes the following:

• Among the eight domains of our service delivery are collaboration, counseling, and prevention and wellness.
• “SLPs play critical roles in health literacy”.
• Our scope of practice includes “interdisciplinary work in … health care [with] collaborative service delivery wherever possible”.

ASHA further states that “this scope of practice does not supersede existing state licensure laws”. As Jenny stated during the seminar, it’s important that we check with our state to find out which activities our license permits. While certain activities may be in our scope of practice, if they’re not within our scope of license, we shouldn’t be engaging in them.

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General approaches to reducing adverse drug events

The 2006 IOM report outlines three general approaches to reducing ADEs.

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Encourage patients to be more active in their own medical care

• Teach patients about the “risks, contraindications, and possible side-effects… and what to do if they experience a side effect” (page 2).
• Patients should actively double-check the medicines that they’re taking and keep good records.
• Inform patients about medication errors when they occur.

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Use technology to reduce adverse drug events

• Electronic prescriptions will ensure legible, complete orders.
• Use online databases to refer to medication information.
• Software tools can automatically check for drug interactions or duplication.

The report states that “all health care suppliers should seek to become high-reliability organizations preoccupied with improving medication safety” (page 3).

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Improve and standardize labeling and packaging of medicines

Some errors occur due to medicines looking or sounding similar. Other errors occur due to difficulty reading or understanding labels and inserts.

A. Berman (2004) points out:

• 25% of all medication errors are due to confusion between similarly-named products.
• 33% of errors are due to confusion between products that look alike.

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9 ways home health clinicians can help

Marek and Antle (2008) discuss many ways that ADEs can be prevented. I highly recommend taking a look at this short book chapter, which is freely available.

An SLP can take responsibility for some of these areas, while playing a supporting role in others. All home health clinicians may participate in these activities, depending on their scope of practice, scope of license, and agency policies.

1. Ensure accurate medication reconciliation between what the MD orders and what the patient is actually taking.
2. Use software to identify adverse drug interactions.
3. Assist patient to obtain the medications. (Enlisting family help; home delivery; medication discount programs)
4. Educate patients regarding their medication using explicit, organized, and understandable material.
5. Teach patient to use a medication chart or other tool.
6. Modify the medication system to accommodate vision or manual dexterity issues.
7. Compensate for cognitive difficulties.
8. Involve patients with decision-making to improve self-efficacy and adherence.
9. Monitor patients over time.

SLPs may feel nervous about these activities

I think the two activities that SLPs feel most nervous about are medication reconciliation (#1) and teaching patients about their medication (#4). Certainly, the way I approach these activities are vastly different from how a nurse would.

Reconciling medications.

Currently in my agency, SLPs, OTs, and PTs play a role in medication reconciliation but it’s limited to data entry. I’m perfectly comfortable with that. I’m competent to copy information from a medication label into the EMR. I can click the button to have the software look for interactions and warnings and read that information to the nurse over the phone.

I’m not competent to judge what to do about any interactions or warnings, and it’s not in my scope of license to make recommendations to my patient. The nurse calls the doctor to resolve any issues and educates my patient about any changes.

Teaching medications

With respect to medication teaching, I don’t provide the initial teaching to my patients. I view my role as helping my patient understand information taught to them by their doctor, pharmacist, or nurse. I always check with my patient’s nurse to make sure I’m accurate in my understanding of the important points. Then I use my expertise to present that in a way that my patient can understand.

Adjusting for low-vision or manual dexterity issues

The only other item in the list above that might give an SLP pause is modifying the patient’s system to account for low vision or manual dexterity issues (#6). This is where we can heavily rely on our OT colleagues.

Even if activities are within our scope of practice, we have to make sure they’re within our scope of license. Your specific home health agency should have their own policies and procedures as well.

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A deeper dive into the SLP’s role

Jenny and Megan pointed out that our role is divided into three main activities:

1. Identify and address communication, cognitive, and physical barriers to taking medications properly.
2. Use resources to assist our patients to understand their medication routines and possible side effects.
3. Develop and teach strategies to improve adherence to medication routines.

In addition, they stated that we shouldn’t discount people who live in assisted living facilities, because mistakes still happen. If the person is cognitively able, they should at least know how many pills they take.

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1. Identify and address communication, cognitive, and physical barriers

As SLPs, we’re likely competent and confident in identifying communication and cognitive-communication deficits that may limit someone’s ability to understand their medication and follow instructions. We can complete formal or informal assessments of verbal comprehension and reading comprehension, ability to read the fine print on labels, memory, reasoning and problem solving skills, and executive function skills.

In addition to any formal assessments we do, Megan pointed out that we should assess our patient’s understanding of their medication routines and their ability to follow it.

We should ask our patients to:

• Show us their medication and explain how they take them.
  
• Tell us what their medication is for.
• Explain what side-effects they’re watching for.
• Tell us what they’d do if they missed a dose or took too much.
• Explain how they get refills.

We should also observe:

• If they’re using a pill box, are they current with taking their doses?
• Are their medications organized?
• Do we see any loose pills on the table or floor?

Physical barriers limit a patient’s ability to follow a medication routine. Depending on the physical barrier, we may be able to address it directly, or we may collaborate with PT or OT.

We should screen or assess our patient’s ability to:

• Get their medication and water.
• Read medication labels.
• Open pill containers and manipulate pills.
• Swallow pills.
• Order and obtain refills.

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2. Use resources to assist our patients to understand their medication

Although SLPs are usually not trained in understanding medication, we can play a role in educating patients (to the extent that our state license and agency policy permit). And CMS expects us to collaborate in educating our patients. That means talking with our nursing staff or calling the physician’s office if it’s a therapy-only case. In addition, we can use the information provided in our EMR or online to help us and our patients understand their medication.

I used to feel that unless I took a semester-long course and really learned medication inside and out, then I shouldn’t be educating on medication. Then last year, I was flabbergasted when a nurse told me she didn’t know anything about a particular medication. In researching this article, I’ve learned that in general, doctors and nurses don’t thoroughly know medications.

As the 2006 IOM report stated, “doctors, nurse practitioners, and physician assistants, for example, cannot possibly keep up with all the relevant information available on all the medications they might prescribe – but with today’s information technologies they don’t have to”. I guess that’s not surprising, given that there are over 10,000 drugs on the market.

We can use resources to gain an initial understanding of the medications and possible side effects, and confirm that through collaboration with other medical staff.

Once we know what to teach, we can use our expertise to teach our patients in a way they can understand and remember.

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3. Develop and teach strategies to improve adherence to medication routines

Megan presented various questions and strategies to improve our patient’s ability to take their medications correctly:

• Would your patient benefit from better organization of the medication?
• Are the pills kept in an accessible but safe place?
• Can you introduce a pill box that might be more helpful?
• Would your patient benefit from an alarm?
• If your patient has low vision, you could try rubber bands on the bottles to differentiate them.

Megan also suggested these therapy ideas:

• “Create a hierarchy for teaching how to fill pill planner. Use different colored/shaped beads.”
• “Take photos of patient’s medication. Have patient match pill to photo that includes a label/description”.
• “Ask your local pharmacist for empty pill bottles to use for practice with your patients”.

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31 strategies to improve adherence

Earlier this year, I wrote a post that laid out a wide variety of strategies to compensate for a memory impairment, including:

• Visual reminders.
• Alarms.
• Apps.
• Pill boxes.
• Pre-packaged doses.
• How to make it a habit.

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My final thoughts

I feel strongly that SLPs have a role in medication education. Problems in communication and cognition lead to a significant number of adverse drug events. Addressing these problems are firmly in our wheelhouse. We have the ability to make a huge impact in the health and well-being of our patients.

We know how to assess and treat communication and cognitive-communication impairments. In addition, we also know how to modify, present, and teach information to people who have impairments in these areas. We should collaborate with the nurse or doctor to ensure we’re teaching the right information.

We can learn about the many tools that are available for medication management systems. We can work with the patient, family, nurse, OT, and PT to determine which system may work best.

If you’re not already participating in medication education, I hope this article provides enough information and resources to help you get started.

What is your involvement with medication education? Do you plan on increasing your role in this area? Please comment below.

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References

Aspden P, Wolcott J, Bootman L, Cronenwett L, editors. Preventing medication errors. Washington DC: Institute of Medicine of the National Academies; 2006. (full book available free as a PDF)

Berman, A. “Reducing medication errors through naming, labeling, and packaging”. Journal of Medical Systems: vol 28 (2004): 9-29. PMID: 15171066.

Chyka, P. “How many deaths occur annually form adverse drug reactions in the United States?” The American Journal of Medicine: vol 109,2 (2000): 122-130.

Gurwitz J, Field T, Harrold L. “Incidence and preventability of adverse drug events among older persons in the ambulatory setting”. JAMA. vol 289 (2003): 1107–16.

Jeetu, G and T Girish. “Prescription drug labeling medication errors: a big deal for pharmacists”. Journal of young pharmacists : JYP vol. 2,1 (2010): 107-11.

Loehr, J and M. Malone. “Home Health Medication Education: How to Ensure Compliance While Remaining within the Scope of Practice.” ASHA Convention presentation (2018).

Marek, K. and L. Antle. “Medication Management of the Community-Dwelling Older Adult“. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 18. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2670/