The grades of evidence (A1-D) are defined at the end of the "Major Recommendations" field.
Description of Practice
The Medication Management Outcome Monitor and the Medication Assessment Tool have been combined into a single assessment tool the "Long Term Care/Medication Outcome Manager (LTC-MOM)." A copy is located in Appendix A of the original guideline document. It is to be used for monitoring and evaluating the usefulness of the Medication Management evidence-based practice guideline in improving outcomes of those individuals residing in nursing home facilities. The LTC-MOM will be completed using the current Medication Administration Record (MAR), resident's chart, Minimum Data Set (MDS), and history and physical examination. The schedule begins with admission and is repeated at 4 month intervals or with an acute change in condition. Medication review is an ongoing process, but especially pertinent at admission, transfer, transition, condition or symptom change, deterioration, function change, new medications, diet changes, or irregularity identification by pharmacist. This tool will help to answer the questions: should a change be made, the medication continued, and/or discontinued. Utilizing a tool to identify and trigger changes in plans of care has been supported by the Institute of Healthcare Improvement.
The following background information will be recorded at each visit to assist in determining if outcomes are met:
- Results of lab studies since last exam
- Total number of scheduled and prn (as needed) medications
- Emergency room (ER) visits/hospitalizations related to adverse drug reactions (ADRs)
- New medications
- Discontinued medications
- Resident/Family Goals of Care related to medications
At least annually:
- Review and update the Cockcroft Gault formula.
- Complete Blood Count, Thyroid Stimulating Hormone (TSH), and Comprehensive Metabolic Profile including liver and kidney functions tests.
Outcome 1: Maintain Functional Status
Functional health will be measured by the MDS-ADL 3.0 Scale and results of the clinician's history and physical examination.
The use of the MDS-ADL scale has repeatedly been found capable of measuring both decline and rate of decline in vulnerable populations with moderate to moderate/high validity and reliability. The current version of the Minimum Data Set (MDS) is 3.0 and was put into practice in 2010. This comprehensive mandated assessment tool is used by nursing homes to assess the resident's functional, medical, psychosocial, and cognitive status. Consistent with former versions, it must be completed within 14 days of admission and updated at quarterly intervals or with significant status changes. Data are collected by trained professionals (e.g. nurses, social workers, and therapists), and each MDS item has its own explicit definition and coding convention. The range of the MDS activities of daily living (ADL) Self performance scale during the designated period is from 0 (independent) to 4 (total dependence) for activities that have occurred three or more times, 7 if the activity occurred 1 or 2 times, or 8 if the activity did not occur at all. The MDS-ADL 3.0 Scale has 10 items including bed mobility, transfer, walk in room and corridor, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. The examiner will sum and record the individual item scores from the most recent MDS-ADL Scale. Higher scores denote greater dependence. (Evidence Grade = C-1)
If declines are noted on either the MDS 3.0 self performance activities of daily living scale (total possible score 0 – 80) or the history and physical examination, review of medication regimen with adjustment of dosages or discontinuation as indicated. (Evidence Grade = D)
As a result of following the medication management guideline, residents will not have a decrease in functional status related to their medication regimen. (Evidence Grade = C-1)
Outcome 2: Decrease Polypharmacy
Nurse practitioners, physician assistants, and or physicians will review and record the total number of routine and as needed medications at each periodic visit. The creatinine clearance level will be calculated on admission, with changes in condition, and at least annually. (Evidence Grade = C-1)
The Cockcroft Gault Score (see Appendix B in the original guideline document) and laboratory results will be used to determine dosing. Major Drug Guides and prescribing references provide medication dosing guidelines for initial as well as individualized suggestions based on disease severity and therapeutic responses. (Evidence Grade = C-1)
- The number of scheduled and as needed (prn) medications will not increase and medications will be congruent with diagnoses with no duplications present. Goal: 9 or fewer scheduled medications with number of administrations no more than 3 different times daily. Example; with 7 different meds: 4 given one time daily and 3 twice daily. The regimen could be 5 meds at 9 am, 2 at noon, and 3 at hour of sleep.
- Medication doses will be appropriate for age/renal/hepatic status of older adults. (Evidence Grade = C-1)
Outcome 3: Avoid Adverse Drug Reactions (ADRs)
The resident's record and physical exam will be used to verify adverse drug reactions occurring in the time from the last periodic exam. (Evidence Grade = D)
- Medications identified as resulting in adverse drug reactions including reactions or ER/hospitalizations will be adjusted or discontinued based on overall plan of care. (Evidence Grade = C-1)
- Monitoring guidelines will be individualized and in place for high risk medications: insulin, digoxin, warfarin, anti-psychotics. (Evidence Grade = C-1)
No adverse drug reactions, no drugs ordered to treat side effects or adverse reactions, and no hospitalizations or ER visits resulting from adverse drug reactions. (Evidence Grade = C-1)
Outcome 4: Decrease Inappropriate Prescribing
The current MAR will be compared to the Beers list, Centers for Medicare & Medicaid Services (CMS) guidelines, and the facility pharmacist's recommendations to ascertain appropriateness of current medication regimen. (Evidence Grade = B-1)
- Medications found to be in conflict with the Beers list, CMS guidelines, and/or facility pharmacist's recommendations should be discontinued or adjusted unless compelling evidence exists for continuance. (Evidence Grade = B-1)
- The Beers list, CMS guidelines, and/or facility pharmacist's recommendations should be used when planning medication initiation, reviewing established medication regimens, or making changes in the medication regimen. (Evidence Grade = C-1)
No inappropriate prescribing as evidenced by the medication regimen which contains no drugs in conflict with the Beers lists, CMS guidelines, and/or pharmacist recommendations. (Evidence Grade = C-1)
Rating Scheme for Strength of Evidence
A1 = Evidence from well-designed meta-analysis or well done systematic review with results that consistently support a specific action (e.g., assessment, intervention, or treatment)
A2 = Evidence from one or more randomized controlled trials with consistent results
B1 = Evidence from a high quality evidence-based practice guideline
B2 = Evidence from one or more quasi-experimental studies with consistent results
C1 = Evidence from observational studies with consistent results (e.g., correlational descriptive studies)
C2 = Inconsistent evidence from observational studies or controlled trials
D = Evidence from expert opinion, multiple case reports, or national consensus reports