By Kim Durand RN, Chronic Care Program Manager, Day Kimball HomeCare

Medication management is one of the most critical services that Day Kimball HomeCare provides to our homebound patients. Whether it’s filling pillboxes or administering a prescription, approximately 10 percent of Day Kimball Home Care’s home health patients require our nurses to administer or pre-pour their medications.

Working with chronically or terminally-ill patients in their homes — especially patients with diabetes, chronic obstructive pulmonary disorder (COPD), heart failure and depression — requires our team to set, review and adapt our goals while helping patients better understand and manage their conditions.

Here are the biggest medication challenges that we encounter, and how we prevent them from turning into crises:

1. Discharge-to-home (mis)communication

Communication about (and adherence to) medication plans is one of the most complex issues for the patients we transition from inpatient facilities to the home. It’s our job to make sure that the medications patients have in their homes match what their physician, hospital or nursing home have prescribed. We do long-term medication monitoring for patients receiving services within Connecticut’s Home Care Program for Elders. Based on their doctors’ orders, we set up a medication planner that dictates what, when and how patients take their meds.

Unfortunately, in situations where there’s no long-term plan in place or families aren’t monitoring and helping manage their loved ones’ care, we see much higher rates of readmission. And while doctors set up a medication plan when the patient leaves the hospital, that plan is only a snapshot in time. The real challenge is managing changes in medication that a patient may need, based on their changing condition, within the home.

2. Interactions can = death

Because patients don’t always think about what can happen if they take over-the-counter NSAIDS (non-steroidal anti-inflammatory medications) and herbal supplements along with their prescribed meds, we ask them to show us everything they take during our home visits. Any over-the-counter medication is dangerous if it’s unintentionally taken with a similar prescription medication.

Most people are not aware that Percocet contains Tylenol, so if you also take over-the-counter Tylenol, you could be getting a dangerous dose. Seniors who have arthritis and take Coumadin should not take Aleve or aspirin, which also thin the blood.

During every visit, we check for drug interactions or duplications. We consult with the at-home patient’s physicians. And we educate patients on the hazards of deviating from their plan.

3. Where did that come from?

During our in-home visits we often discover that other specialists have prescribed medication for the patient without the knowledge of the primary physician. We also discover and correct glitches that may occur with the patient’s pharmacy.

In one home visit, we discovered that a patient was getting duplicate refills of a blood pressure-and-arrhythmia controlling beta blocker — one brand name, one generic — both coming to his home through the drug store’s auto-refill plan (a program we strongly discourage our patients from enrolling in.)

Another at-home patient had been prescribed oxycontin by her nursing home — without her primary doctor’s knowledge — before her discharge. We consulted with the doctor to determine if the oxycontin should be discontinued, maintained or increased.

We often get phone calls from patients that are unsure if they have been prescribed the right medication – “I opened my bottle and this pill looks different – I’m not sure it’s my Lasix.“ We call the pharmacy and the provider to identify the pill in question and determine if it should be in the bottle.

4. Too much or too little

For patients with cardiovascular programs and diabetes, anticoagulants and insulin pose big risks in dosing and compliance. We regularly monitor the blood levels of our homebound patients on Coumadin to make sure their INR (bleeding time) count is within a normal range.

We often see diabetes patients negotiate how much insulin they take based on how they perceive they are managing their diet. We educate them to not change their insulin levels without checking with their physician. Patients who can’t see their insulin syringe need our help to administer the drug.

5. It’s all in the timing

When a patient comes home from the hospital, they have a lot of adapting to do. They may not hear (or remember) all they were told by their doctor when they left the hospital. This is where patient education in the home really makes a difference.

A patient was told by her doctor to take her insulin every morning at 7 a.m. One morning, she woke up exhausted, took her insulin and went back to sleep, forgetting the doctor’s equally important order to always eat breakfast. When she awoke at 11 a.m., hypoglycemic and agitated, she called our nurse, who explained what was happening to her body at that moment, and why the right food at regular intervals was critical to managing her condition.

6. Communication is key

Here’s a story that reinforces why we must continue to go into our patients’ homes, monitor their medication plan and help them understand its importance. Early in my nursing career, Nitropaste was used to control chest pain. In reviewing one of my patient’s medication plans, I asked him to bring out and show me everything he took by mouth and through his skin. He said, “There’s one more medication I need to get,” then pulled out a locked box and gently extracted a tube of Nitropaste. This patient perceived that the Nitropaste was nitroglycerin and that if he put it on his chest hewould explode. The patient didn’t read the label until he went to the pharmacy for a refill. His unwarranted fear was never corrected until I reviewed his plan!

The good news? Most of our in-home patients are becoming more comfortable asking questions. They expect us to give them knowledge about the medications they’re taking and how to take them. There are times where a patient says, “My gut says something isn’t right.” Our response is always “Go with your gut!”

Communication within our health system is also critical to serving patients at home. While we’re working on the technology that will seamlessly transmit patients’ information between primary care physicians, specialists and pharmacies, Day Kimball’s Care Transitions program has already made it easier for everyone who serves our home care patients to communicate more effectively. We’re giving our health care co-partners access to home patients’ electronic medical records. And we’ve developed a standard medications form that our patients take with them to their physician appointments.

Kim Durand, RN has supported patients in her community for more than 27 years. After beginning her career in Day Kimball Hospital’s medical-surgical unit, she was loaned to its home health care division and immediately loved the hands-on nature of the work.

After receiving her chronic care management certificate from Sutter Institute four years ago, Kim helped build and launch Day Kimball HomeCare’s chronic care management program, which focuses the care on the patient and the challenges they face in self-managing their illness. An active member of the Connecticut Association for Healthcare at Home, she chairs its Clinical Supervisors’ SIG group and sits on its Future of Homecare Workgroup committee.