Improving posthospital medication management for chronically ill older adults

For chronically ill older adults who take multiple medications, a hospital stay can result in various medication-related changes.

  • Nurses administer their medications to them.
  • Their medication schedules may be altered due to hospital policy.
  • Specific drugs they receive may change depending on the hospital formulary.
  • Medication dosages and frequencies may be altered.
  • New medications may be added or current ones may be discontinued.

A study found nearly all older patients (96%) discharged from hospitals had at least one medication change from their previous regimens and less than half were informed of the specific changes. So what can nurses do to help older adults manage their medications safely after they’re discharged?

Reconcile medications

Using medications safely, which includes reconciling new and previous medication regimens, is one of The Joint Commission’s National Patient Safety Goals. Take the time to compare medication regimens before and after the patient’s hospital stay for consistency, and verify with the prescriber that any changes you find are intentional and accurate.

Assess and address self-management abilities

Patients don’t self-administer their medications in the hospital, so you need to assess their understanding of and ability to manage their medications. Perform this assessment as soon as possible after admission so you and your colleagues have enough time to identify problems and solutions or make referrals. To promote safer transitions, assess three key areas—psychomotor skills, medication knowledge, and self-management routines.

Psychomotor skills

Observing how an older adult handles medications can help you pinpoint problems you may overlook if you rely on patient self-report alone. For instance, you may identify difficulty with fine motor coordination (such as handling an inhaler) or faulty technique (for instance, not shaking the inhaler). Evaluate the patient’s psychomotor skills—administering eyedrops, self-administering subcutaneous injections, applying topical patches, and opening packages, as appropriate.

Medication knowledge

Administering medications in the hospital is an ideal time to assess the older adult’s understanding of the medication and regimen, evaluate previous teaching, clarify misunderstandings or changes, and reinforce or expand on previous teaching, as needed. Assess the patient’s knowledge of the medication name, purpose, dosage, schedule, and side effects. Correct faulty information. (See Drugs linked to readmissions or adverse drug events.)


Self-management home routines

Older adults living in the community identified helpful strategies to manage their medications. They described establishing routines, simplifying their routines (schedules or ways to get their medications), and using visual cues (recognizing pills by color). To help customize discharge medication teaching, ask patients about their home routines.

Involve patients and families early in planning discharge

Living situations, abilities, and available resources vary among older adults. Family and other informal caregivers are a valuable support to both older adults and the healthcare team. In many cases, they may want to be involved when a loved one is in the hospital but may face barriers to getting information in a timely manner. To improve the transition to the home, nurses and other interdisciplinary team members should take a proactive approach, working with patients and family on the discharge plan as soon as possible after admission.

Provide clear medication instructions at discharge

As discussed earlier, reconciling medications is crucial to a smoother posthospital transition. Before discharge, the interdisciplinary team should collaboratively review all medications using multiple documents—including home medication lists, current medication administration record, discharge documentation (instructions, summaries, or referrals), and prescriptions—to check for appropriateness and consistency.

When teaching older adults and their families, clearly identify and discuss medication changes and address practical aspects of obtaining prescriptions, such as medication insurance coverage, the need for preauthorization, pharmacy location, and medication availability. The teach-back approach is a good way to assess and ensure patients’ and home caregivers’ understanding of the medication regimen and other discharge instructions. Evidence suggests this approach increases information retention, improves medication adherence, smoothes the transition from hospital to home, and helps prevent medication errors. Discharge instructions are helpful not just for patients and their home caregivers but also for home care clinicians, who use them to guide assessment and teaching.

Strategies to improve medication adherence

The healthcare team should work to reduce dosing frequency when possible and identify medication routines that can bolster patients’ adherence.

Reduce dosing frequency

Several studies show patients are more likely to adhere to their medication regimens if they take medications once daily rather than several times a day. If an older adult at home tends to forget doses, consult with the prescriber, who may be able to reduce dosing frequency or make schedule changes that improve adherence.

Identify medication routines

Older adults differ in how they organize and manage their medications. Identifying your patient’s unique home routines can help you individualize medication teaching, which can enhance adherence. (For online resources on caring for older adults, see Helpful resources for older adult care.)

Collaboration is crucial

In older adults, posthospital medication management can be complex, requiring collaboration among nurses, other healthcare team members, patients, and family members. Caring for hospitalized older adults is a valuable opportunity for clinicians to promote a safer transition to the home by:

  • performing medication reconciliation during transitions in care
  • completing admission assessment of the patient’s abilities, understanding, and routines used to manage medications at home
  • involving the patient and family caregivers in developing the discharge plan
  • collaborating with other healthcare team members to address specific issues, such as home healthcare referrals and dosing frequency
  • providing individualized medication teaching throughout hospitalization and at discharge.

References

Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002-12.

Coleman CI, Limone B, Sobieraj DM, et al. Dosing frequency and medication adherence in chronic disease. J Manag Care Pharm. 2012;18(7):527-39.

Corbett CF, Setter SM, Daratha KB, Neumiller JJ, Wood LD. Nurse identified hospital to home medication discrepancies: implications for improving transitional care. Geriatr Nurs. 2010;31(3):188-96.

Foust JB. Improving quality of care and safety during transitions in care. In: Sheldon LK, Foust JB. Communication for Nurses: Talking with Patients. 3rd ed. Sudbury, MA: Jones & Bartlett; 2013.

Foust JB, Vuckovic N, Henriquez E. Hospital to home health care transition: patient, caregiver, and clinician perspectives. West J Nurs Res. 2012;34(2):194-212.

Joint Commission, The. 2014 Hospital National Patient Safety Goals. www.jointcommission.org/standards_information/npsgs.aspx.

Kanaan AO, Donovan JL, Duchin NP, et al. Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers Criteria Medications. J Am Geriatr Soc. 2013;61(11):1894-9.

Kornburger C, Gibson C, Sadowski S, Maletta K, Kingbeil C. Using “teach-back” to promote a safe transition from hospital to home: an evidence-based approach to improving the discharge process. J Ped Nurs. 2013;28(3):282-91.

Lynn SJ. Adverse drug reactions in the elderly: Can we stem the tide? Am Nurse Today. 2012;7(1). americannursetoday.com/adverse-drug-reactions-in-the-elderly-can-we-stem-the-tide.

Saini SD, Schoenfeld P, Kaulback, K, Dubinsky MC. Effect of medication dosing frequency on adherence in chronic diseases. Am J Manag Care. 2009;15(6):e22-33.

Swanlund SL. Successful cardiovascular medication management processes as perceived by community-dwelling adults over age 74. Appl Nurs Res. 2010;23(1):22-9.

Unroe KT, Pfeiffenberger T, Riegelhaupt S, et al. Inpatient medication reconciliation at admission and discharge: a retrospective cohort study of age and other risk factors for medication discrepancies. Am J Geriatr Pharmacother. 2010;8(2):115-26.

Woodruff K. Preventing polypharmacy in older adults. Am Nurse Today. 2010;5(10). americannursetoday.com/preventing-polypharmacy-in-older-adults.

The authors work in the Department of Nursing at the College of Nursing and Health Sciences, University of Massachusetts, Boston. Janice B. Foust is an assistant professor in the College of Nursing. Gretchen A. Kilbourne is doctoral candidate.

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