Potentially Inappropriate Medications

Common in Home Health – Increase Hospitalization Rates Up to 33%

Potentially inappropriate medications (PIMs) refer to those medications that create greater complication risk for elderly patients due to the altered pharmacodynamics and pharmacokinetics among the elderly. Such medications are not necessarily inappropriate, because only the prescriber’s clinical judgement, in consultation with individual patients, can weigh the pros and cons of each prescription. PIM use has been connected with falls, adverse drug reactions, emergency department visits, and hospitalizations.¹⁻⁷ Nevertheless, high levels of PIM-taking persist across various segments of the elderly population. Among ambulatory care patients, it has been measured as high as 13%.⁸⁻⁹ In long-term care facilities, PIM usage reaches 50%.¹⁰ On the other hand, some studies have questioned the ability of PIMs to predict negative outcomes.¹¹⁻¹²

Patients enrolled in Medicare-certified home health demonstrate high PIM usage. This stems in part from the higher frailty and morbidity among this group, which is also connected with higher polypharmacy. A 2012 study using the 2003 Beers criteria for PIMs finds that 38% of home health patients demonstrated PIM usage.¹³ The Beers criteria has been updated since then, and nationwide PIM awareness efforts progress. For these reasons, Dr. Matthew Lohman and colleagues recently reas- sessed PIMs in home health.¹⁴

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Dr. Lohman and colleagues analyzed the records of 132 home health agencies, across 32 states, and 87,780 patients. All patients were age 65+. With PIM usage measured at 34.4% under the current Beers criteria, they found no meaningful improvement since the last major study. PIM usage was determined based on home health start of care assessments. Therefore, the PIMs detected in this study originated prior to home health services, and the potential effect of home health medication management would not be detected in this study. Even after risk-adjusting for morbidity, researchers found that PIM usage correlated with an increase in hospitalization risk reaching 33%. Their findings support the proposition that PIM usage should be evaluated at various points throughout the continuum of care to protect patient safety. The authors of the current study postulate the causes of PIM usage among home health patients may include patients taking non-prescription PIMs without reporting it, the necessities of complex medical cases, and the miscommunications that can occur in care transitions. 

Whenever homebound patients experience a care transition such as a discharge from facility to home or even when they receive a new medication regimen, a referral for home health medication reconciliation and medication teaching may be appropriate. In a study of 770 patients discharging from hospital care to home health, 100% of medication lists had errors.¹⁵ A separate study found that when home health nurses reviewed medications at the patient’s home, the resulting medication list differed from the patient’s medical records 88.4% of the time.¹⁶ The home health care model, with in-home access and visits often lasting an hour or more, uniquely positions nurses to accurately evaluate your patient’s medication-taking patterns and to painstakingly reconcile medication lists from the various prescribers. A Five Star Home Health nurse will never change a prescription or even suggest to a patient that a prescription should be changed. A Five Star nurse will report the most accurate accounting of your patient’s medication-taking possible, report any patient concerns or obstacles to adherence, and highlight any detected PIMs for physician consideration. Home-based medication reconciliation programs have been shown to reduce the risk of hospitalization and of death.¹⁷⁻¹⁹ While research shows in-home medication management in general reduces unnecessary hospitalization, Medicare data shows that the patients you refer to Five Star Home Health in particular prove even less likely to require hospitalization compared to risk-adjusted national averages. Compared to other home health agencies, the patients you refer to Five Star prove 18% less likely to require hospitalization during the home health episode.

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References:

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