A new approach to managing medication

Neva Hantover keeps her medications in a locked box next to her bed. Once a week, a nurse at the Tockwotton Home where she lives fills a cassette with her daily doses, and Hantover takes it from there.
She can’t name all the pills or tell them all apart by shape and color, but she keeps a list in her walker, and she knows what she’s taking: a painkiller for her arthritis, plus Tylenol; an antidepressant; something against constipation; and calcium and fiber supplements.
Sharp-minded and still full of creativity at 86, the widowed jewelry maker wouldn’t dream of living without pills. They keep her going, she says – especially the antidepressant, a powerful drug that has finally controlled a condition that ravaged her life for decades.
“It runs in my family,” she said on a recent morning. Her father and her son both committed suicide; she’d never want to bring that kind of grief to her daughters, yet until three years ago, she was in and out of the hospital frequently. This pill, she said, “keeps me alive.”
Hantover, one of 24 assisted-living residents at Tockwotton, is a good example of the critical role that medications play in seniors’ lives – and of the challenges involved in managing a complex drug regimen, especially as memory, dexterity and other skills fade with age.
Now, as part of its Elder Experience Lab (formerly known as the Nursing Home of the Future), the Business Innovation Factory is looking at ways to make the process easier for seniors, and by doing so, help them be more independent and have a stronger voice in their own care.
The project is part of a broader effort to use technology, systems redesign and other strategies to improve seniors’ lives, with a focus on areas that are really important to them and where there are tangible opportunities for innovation.
Medication management, said Melissa Withers, executive director of BIF, is clearly one such area, because it’s a major challenge for seniors and their caregivers. It is handled in many different ways, and there is a lot at stake in terms of safety and effectiveness – not to mention seniors’ independence. If they can’t take their pills, they may not be able to live alone. The problem, as a BIF report put it, is that the demands of managing medications “leave many elders dependent on assistance.” The current system “is designed around a medical model, not around the needs, behaviors and capabilities of elders themselves.”
So last March, the BIF team set out to understand how seniors experience taking medications, starting with interviews with staff, residents and family members at Tockwotton, the East Side nursing home and assisted-living facility that is the “home base” of the project.
The two units handle medications very differently. In assisted living, seniors take their own pills, though most get help preparing each week’s doses, as Hantover does. In the nursing home, meanwhile, the staff administers the medications directly, taking the pills out of 30-day blister packs and logging it all in a binder that includes patient-by-patient directions.
The latter wasn’t as big a focus for BIF, because nursing home residents are, in most cases, well past the point of being able to manage their own medications – many have dementia or they are just too frail.
But a few minutes with technician Alda Lubrano and her medication cart are still very instructive. Until recently, before “culture change” – a reorientation by nursing home staff to the daily rhythms of residents’ lives, among other things – Lubrano’s job was a little easier. Traditionally, nursing homes have given seniors their pills at specific times – if breakfast was at 8 a.m., for example, everyone got the 30-minutes-before pill at 7:30 a.m. Now, however, seniors get to sleep as late as they want, and Lubrano has to adjust the prescribed schedules accordingly. The cart is active all day. Culture change also has meant that Lubrano is consistently assigned to the first floor, so she knows her residents and how they like to take their pills, “which is a big thing,” said Tockwotton administrator Kevin McKay. Given that the nursing home residents are often too frail to speak up if a medication is making them sick or drowsy, consistent staff assignments also have another benefit, noted Dorothy Shea, director of nursing:
“The staff picks up those things,” she said. “The residents may not be able to verbalize, ‘I feel more tired.’ But because [staff] see them every single day and they know them so well, they’ll say, ‘The last two days, Mrs. Soandso has been nodding off in her chair, and she doesn’t normally do that.’ ”
In assisted living, on the other hand, seniors’ experience is a lot closer to what it would be in the community. Well before she moved into Tockwotton, for example, Hantover had an aide at home who sorted her medications for her, and she’s still responsible for taking the pills on time, just as she was at home.
There are advantages to being at Tockwotton, however: Her antidepressant interacts badly with specific foods, and the kitchen staff here has a list, so she needn’t worry about accidentally eating, say, eggplant or Cheddar.
And for the first time, she has a single doctor, medical director Dr. Stefan Gravenstein, who is looking at every aspect of her care.
One of the key findings of the BIF review, a longstanding concern for Gravenstein, is that many seniors may be overmedicated – a phenomenon known as “polypharmacy.” It’s easy for that to happen, McKay noted, when a senior sees a geriatrician, a cardiologist, a rheumatologist, an endocrinologist, and each prescribes one or two drugs to deal with the specific condition he is treating, but nobody coordinates it all.
The result can be duplication, diminished effectiveness – which happened to Hantover when a painkiller countered her antidepressant’s benefits – and adverse reactions, the BIF review noted. The wrong combination of pills may make seniors sicker and more frail, and it may not be caught because it seems like it’s just the progression of their illnesses. Disturbingly, the BIF team also found, it is “expected” that when seniors go into institutional care, they will take more and more pills. Not all of this is bad, noted Shea – nutritional supplements such as vitamin D3, which is believed to help prevent falls, is a good addition. But the BIF review noted that the risk of errors and side effects also increases.
“Our work makes clear that there is a need for systems-level thinking about medication and the effect increasing medication has on elders,” the team concluded.
So what now?
Some of the proposed solutions are for industry to take on: smarter pill sorters, for example, that allow seniors to keep drug information with their doses.
More immediately, however, the review identified opportunities to improve seniors’ experience by doing the kind of work Gravenstein does, taking a comprehensive look at their medical care and drug regimens, and by giving seniors and their families more tools to understand and manage medications.
After seeing the BIF report, McKay said, Tockwotton is considering hiring a “medication coach,” and it’s also looking at resident- and family-education sessions. Already, he said, the team encourages family members to be active in their loved ones’ care, ask questions and learn about the diagnoses and treatments involved.
Hantover’s daughter Mare Davis takes that responsibility very seriously. On a recent visit to Tockwotton, she described herself as an interpreter of sorts: She accompanies her mother on doctors’ visits, asks questions, listens carefully, then follows up with her mother afterward, explaining everything and reminding her of key points.
“There’s a list of medications,” she said, “and there’s a list of things you have to pay attention to – your emotional state, your arthritis, your foot sore. Those priorities are constantly shifting.” •