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Best Practice Tools
"Best Practices for Improvement in Management of Oral Medications" -Teleconference Supplement- OASIS ANSWERS, Inc. 2005


MEDICATION ASSESSMENT PROTOCOL
Purpose: To provide a standardized approach to evaluating patient ability to administer medications.
Instructions Clinician Observation/Assessment
9 Ask patient to demonstrate how he/she takes his/ · Observe the patient performing preparatory activity
her medication.
(e.g., gathering medication supplies or moving to area 9 Ask if the patient has any help to prepare or select where medications are routinely stored/organized).
the appropriate medications.
· Is the process organized?
· Identify compliance aids used.
· If the patient does have assistance, determine
(through observation and interview) if the assistance is necessary. Once the medication supplies are assembled (or · Is the process appropriate as described?
· Correct dosage, time, and frequency?
9 Ask the patient to describe how he or she would · Check the patient's response against the directions
proceed with taking his or her medicines (i.e., ask for his or her specific medications.
specifically, "What would you do first? Second?" If ability to sequence the multi-step medication · Does the patient demonstrate ability to appropriately
administration task is not evident: complete all steps in the task? 9 Ask the patient to demonstrate a multi-step · Selects the appropriate bottles
medication administration task (i.e., "Please show · Opens each one and selects the correct dosage
me how you would open your medicine bottles and prior to closing lid(s) take your medication.") · Takes medication as directed
· Closes lid(s) and returns bottles to storage area.
· Review calendar, diary, list, pillbox, etc. to determine
9 As part of the comprehensive assessments AND 9 On an ongoing basis.
· Select one medication with known start date and
count pills to verify compliance.
· Does patient have any established daily routines
which are, or could be, tied-in to medication The Medicare Quality Improvement Organization for Pennsylvania
Medication Assessment Protocol "Best Practices for Improvement in Management of Oral Medications" OASIS ANSWERS, Inc. 2005 This material was developed by Linda Krulish, PT, MHS, and Stephanie Mello Gaskell, MS, MBA, RN, COS-C, and distributed by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization for Pennsylvania, under contract with the Centers for Medicare & Medicaid Services (CMS). The views presented do not necessarily reflect those of CMS. Publication number 7SOW-PA-HH05.125







MEDICATION NON-ADHERENCE (staff education tool)
Purpose: To promote a comprehensive and standardized approach to evaluating the presence and possible
underlying causes of medication non-adherence.

When general assessment findings suggest patient is not taking oral medications as prescribed, assess further: Potential Non-
Is there evidence to support/suggest that patient/caregiver does not understand medication regimen? · "I'm not having (symptom) anymore, so I'm not sure whether to
keep taking this." · "That makes my stomach upset, so I try not to take it."
Is there evidence to support/suggest that patient's/caregiver's inability to read is affecting medication compliance? · Unable to read medication name, frequency, dose, other
Is there evidence to support/suggest that patient is limiting medication use to save drug (i.e. to save money)? · "I take it when I really need it."
· "I sometimes only take half the ordered amount."
Fear of Addiction*
Is there evidence to support/suggest that patient is limiting medication use due to concerns he or she will become addicted? · "I want to get off that stuff."
· "I only take it when I can't stand it anymore."
Drug Diversion or
Is there evidence to support/suggest that patient is taking too much · "I need a refill; the bottle spilled in the sink."
· "Even doubling the prescribed amount does not touch the pain."
(do not assume intentional over-medicating without evaluating for trueineffectiveness of current meds, need for adjuvant therapy, etc.) Is there evidence to support/suggest that the patient's medication non- compliance may be due to general beliefs or expectations about health and illness?
· "If he is meant to get better, it will happen."
· "If I take the pills, it will show a lack of faith."
Medication Non-adherence (staff education tool) "Best Practices for Improvement in Management of Oral Medications" OASIS ANSWERS, Inc. 2005


Is there evidence to support/suggest that the patient is forgetting to take medications, or forgetting that medications have already been taken – resulting in non-compliance? · "I usually take one after lunch, but my daughter called, and I
can't remember if I took it." · pills found in chair, on table by cup, etc.
· incorrect pill counts
· signs of ineffective drug therapy
Is there evidence to support/suggest that patient/caregiver non- adherence is due to functional deficits? · fine motor/gross motor/mobility
· vision
· swallowing
Is there evidence to support/suggest that the patient's medication administration methods lack organization? · bottles/pills in multiple locations
· unable to locate all medications
· reported administration methods vary from day to day
· lack of established or predictable routines (sleep, meals, ADLs,
*May not affect patient's ability to take medications, therefore may not impact M0780 scoring
Referrals should be made based on patient need, state practice acts, and agency policy.
The Medicare Quality Improvement Organization for Pennsylvania
Medication Non-adherence (staff education tool) "Best Practices for Improvement in Management of Oral Medications" OASIS ANSWERS, Inc. 2005 This material was modified from The Home Care Comprehensive Assessment and Drug Regimen Review: Competency Assessment & Training Program for Home Care Therapists, and distributed by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization for Pennsylvania, under contract with the Centers for Medicare & Medicaid Services (CMS). The views presented do not necessarily reflect those of CMS. Publication number 7SOW-PA-HH05.125 MANAGING YOUR MEDICINES
Many people need help in managing their medicines. One of our goals in home care is to help you understand the purpose of your medicines and how to take them correctly.
You can help your home care nurse or therapist understand the type of help you might need by completing the table below.
Place a 5 in the box if the statement applies to you
I have new medicines.
I have changed medicines.
I don't understand the instructions related to my medications.
I am not sure how my medicines help my condition.
I don't think that my medicines help me.
I am concerned about side effects.
I don't always remember to take my medicines at the right time.
I have trouble reading or seeing small print instructions on medicine I have trouble holding the small pills or opening the packaging or the medicine bottles.
I have trouble paying for my medicines.
Please write down any other concerns you may have: The Medicare Quality Improvement Organization for Pennsylvania
Medication Management Patient Self Assessment – QMAP "Best Practices in Improvement in Management of Oral Medications" OASIS ANSWERS, Inc. 2005 This material was developed by Lisa Gorski, MS, APRN, BC, CRNI, and distributed by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization for Pennsylvania, under contract with the Centers for Medicare & Medicaid Services (CMS). The views presented do not necessarily reflect those of CMS. Publication number 7SOW-PA-HH05.125 MED TEACHING STRATEGIES
Purpose: To promote a consistent approach to assessing, teaching, and evaluating the patient's knowledge
and ability related to the Improvement in Management of Oral Medications outcome measure.
Make sure comprehensive assessment includes learning assessment and barriers:
… Sensorimotor barrier? … Language barrier? … Environmental barrier? … Pain/discomfort? … Cognitive barrier? … Cultural/religious practices? … Emotional barrier? … Poor motivation? … NO BARRIERS. READY TO LEARN ? Make sure teaching includes aspects that can improve self-administration:
… Visual recognition of the drug?… Purpose? … Dosing & administration?… Brand & generic names? … Expected duration of therapy?… When to take medication relative to meals, sleep, etc?… What to do in case a dose is missed?… What to do if the condition being treated becomes/remains a problem? Make sure to evaluate and document the patient's or caregiver's response to
your teaching:
… Needs review?
… Repeats knowledge with cue(s) OR performs actions under supervision?
… Verbalizes knowledge/performs actions spontaneously
The Medicare Quality Improvement Organization for Pennsylvania
Med Teaching Strategies"Best Practices for Improvement in Management of Oral Medications" OASIS ANSWERS, Inc. 2005 This material was developed by Linda Krulish, PT, MHS, and Stephanie Mello Gaskell, MS, MBA, RN, COS-C, and distributed by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization for Pennsylvania, under contract with the Centers for Medicare & Medicaid Services (CMS). The views presented do not necessarily reflect those of CMS. Publication number 7SOW-PA-HH05.125 MEDICATION SIMPLIFICATION PROTOCOL:
Purpose: To encourage a standardized and collaborative approach to simplifying complex medication
regimens
.
Use: Add triggers to comprehensive assessment to target patients for medication reduction/simplification strategies:
Is there opportunity to simplify the Is patient taking > 8 medications? patient's drug regimen? 1) Use the fewest medications possible in the simplest form to achieve the desired treatment goal.
2) Eliminate preventable drug-related adverse events.
3) Use non-pharmacological therapies in place of medications when possible.
4) Improve patient medication regimen adherence and independence.
Process: Agency staff will work collaboratively with the organization or community-based pharmacist and/or physician
to apply criteria and meet goals.
Medication Simplification Steps:
1) Remove/discard unnecessary or expired drugs to prevent confusion.
2) Encourage use of a single pharmacy to enhance regimen review and collaboration with pharmacist.
3) Consider non-pharmacologic alternatives.
4) Coordinate administration times with established sleep and activity patterns/routines.
5) Decrease administration frequency, using sustained-release or long acting products.
6) Reduce multiple medications to treat a single condition, unless combination therapy is intentional.
7) Discontinue/substitute cautionary medications known to be problematic for geriatric patients (e.g., "Beers References for Protocol Development:"Medication Regimen Simplification" QMWeb – accessed 02/03/04http://mqa.dhs.state.tx.us/qmweb/MedSim.htmFick, DM, Cooper, JW, Wade, WE, Waller, JL, Maclean, JR, and Beers, MH. (2003) Updating the Beers Criteria for Potentially InappropriateMedication Use in Older Adults. Arch Intern Med; 163: 2716-2724. (including correction note published Arch Intern Med 164:298.)Beers, MH. (1997) Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Arch Intern Med; 157:1531-6.
Texas Health Care Association Website, Best Practices http://www.txhca.org/BestPractices/MedMgmt/medbeer1.pdfAccessed 02/03/04Ugalino, JA. (2001) Understanding the Pharmacology of Aging. Hospital Physician Medical Practice for Staff & Residents, Geriatric Medicine BoardReview Manual, April; 1(4).
The Medicare Quality Improvement Organization for Pennsylvania
Medication Simplification Protocol – QMAP "Best Practices for Improvement in Management of Oral Medications" OASIS ANSWERS, Inc. 2005 This material was developed by Linda Krulish, PT, MHS, and Stephanie Mello Gaskell, MS, MBA, RN, COS-C, and distributed by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization for Pennsylvania, under contract with the Centers for Medicare & Medicaid Services (CMS). The views presented do not necessarily reflect those of CMS. Publication number 7SOW-PA-HH05.125 STEPS to MEDICATION SIMPLIFICATION
Multiple Meds for Single
(MD, Pharm, RN, Patient/Caregiver) Coordinate Doses with
Established Daily Routines
(MD, Pharm, RN, PT, OT, SLP, Aide, Patient/Caregiver) (MD, RN, PT, OT, Aide, Patient/Caregiver) (MD, Pharm, RN, PT, OT, SLP, Patient/Caregiver) (RN, PT, OT, SLP, Patient/Caregiver) Medication Simplification Protocol – QMAP "Best Practices for Improvement in Management of Oral Medications" OASIS ANSWERS, Inc. 2005 This material was developed by Linda Krulish, PT, MHS, and Stephanie Mello Gaskell, MS, MBA, RN, COS-C, and distributed by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization for Pennsylvania, under contract with the Centers for Medicare & Medicaid Services (CMS). The views presented do not necessarily reflect those of CMS. Publication number 7SOW-PA-HH05.125 BEERS CRITERIA
2002 Criteria for Potentially Inappropriate Medication Use in Older Adults: Independent of Diagnoses or
Conditions
Severity
(High or Low)
Propoxyphene (Darvon) and combination
Offers few analgesic advantages over acetaminophen, yet has the products (Darvon with ASA, Darvon-N, and
adverse effects of other narcotic drugs. Darvocet-N)
Indomethacin (Indocin and Indocin SR)
Of all available nonsteroidal anti-inflammatory drugs, this drug produces the most CNS adverse effects. Pentazocine (Talwin)
Narcotic analgesic that causes more CNS adverse effects, including confusion and hallucinations, more commonly than other narcotic drugs. Additionally, it is a mixed agonist and antagonist. Trimethobenzamide (Tigan)
One of the least effective antiemetic drugs, yet it can cause extrapyramidal adverse effects. Muscle relaxants and antispasmodics: Most muscle relaxants and antispasmodic drugs are poorly tolerated methocarbamol (Robaxin), carisoprodol
by elderly patients, since these cause anticholinergic adverse effects, (Soma), chlorzoxazone (Paraflex),
sedation, and weakness. Additionally, their effectiveness at doses metaxalone (Skelaxin), cyclobenzaprine
tolerated by elderly patients is questionable. (Flexeril), and oxybutynin (Ditropan). Do not
consider the extended-release Ditropan XL.
Flurazepam (Dalmane)
This benzodiazepine hypnotic has an extremely long half-life in elderly patients (often days), producing prolonged sedation and increasing the incidence of falls and fracture. Medium- or short- acting benzodiazepines are preferable. Because of its strong anticholinergic and sedation properties, amitriptyline (Limbitrol), and perphenazine-
amitriptyline is rarely the antidepressant of choice for elderly amitriptyline (Triavil)
Doxepin (Sinequan)
Because of its strong anticholinergic and sedating properties, doxepin is rarely the antidepressant of choice for elderly patients. Meprobamate (Miltown and Equanil)
This is a highly addictive and sedating anxiolytic. Those using meprobamate for prolonged periods may become addicted and may need to be withdrawn slowly. Doses of short-acting benzodiazepines: doses Because of increased sensitivity to benzoadiazepines in elderly greater than lorazepam (Ativan), 3 mg;
patients, smaller doses may be effective, as well as safer. Total daily oxazepam (Serax), 60 mg; alprazolam
doses should rarely exceed the suggested maximums. (Xanax), 2 mg; temazepam (Restoril), 15 mg;
and triazolam (Halcion), 0.25 mg
Long-acting benzodiazepines: chlordiazepoxide These drugs have a long half-life in elderly patients (often several days), producing prolonged sedation and increasing the risk of falls and fractures. Short- and intermediate-acting benzodiazepines are (Librax), diazepam (Valium), quazepam
preferred if a benzodiazepine is required. (Doral), halazepam (Paxipam), and
chlorazepate (Tranxene)
Disopyramide (Norpace and Norpace CR)
Of all antiarrhythmic drugs, this is the most potent negative inotrope and therefore may induce heart failure in elderly patients. It is also strongly anticholinergic. Other antiarrhythmic drugs should be used. Digoxin (Lanoxin) (should not exceed 0.125
Decreased renal clearance may lead to increased risk of toxic effects. mg/d except when treating atrial arrhythmias) Short-acting dipyridamole (Persantine)
Do not consider the long-acting dipyridamole (which has better properties than the short-acting in older adults) except with patients with artificial heart valves. May cause orthostatic hypotension. Methyldopa (Aldomet) and methyldopa-
May cause bradycardia and exacerbate depression in elderly hydrochlorothiazide (Aldoril)
BEERS CRITERIA
Reserpine at doses 0.25 mg May induce depression, impotence, sedation, and orthostatic Chlorpropamide (Diabinese)
It has a prolonged half-life in elderly patients and could cause prolonged hypoglycemia. Additionally, it is the only oral hypoglycemic agent that causes SIADH. Gastrointestinal antispasmodic drugs: GI antispasmodic drugs are highly anticholinergic and have dicyclomine (Bentyl), hyoscyamine (Levsin
uncertain effectiveness. These drugs should be avoided (especially and Levsinex), propantheline (Pro-Banthine), for long-term use).
belladonna alkaloids (Donnatal and others),
and clidinium-chlordiazepoxide (Librax)
Anticholinergics and antihistamines: All nonprescription and many prescription antihistamines may have chlorpheniramine (Chlor-Trimeton),
potent anticholinergic properties. Nonanticholinergic antihistamines diphenhydramine (Benadryl), hydroxyzine
are preferred in elderly patients when treating allergic reactions. (Vistaril and Atarax), cyproheptadine
(Periactin), promethazine (Phenergan),
tripelennamine, dexchlorpheniramine Diphenhydramine (Benadryl)
May cause confusion and sedation. Should not be used as a hypnotic, and when used to treat emergency allergic reactions, it should be used in the smallest possible dose. Ergot mesyloids (Hydergine) and cyclandelate Have not been shown to be effective in the doses studied.
Ferrous sulfate 325 mg/d Doses 325 mg/d do not dramatically increase the amount absorbed but greatly increase the incidence of constipation. All barbiturates (except phenobarbital) except Are highly addictive and cause more adverse effects than most when used to control seizures sedative or hypnotic drugs in elderly patients. Meperidine (Demerol)
Not an effective oral analgesic in doses commonly used. May cause confusion and has many disadvantages to other narcotic drugs. Ticlopidine (Ticlid)
Has been shown to be no better than aspirin in preventing clotting and may be considerably more toxic. Safer, more effective alternatives exist. Ketorolac (Toradol)
Immediate and long-term use should be avoided in older persons, since a significant number have asymptomatic GI pathologic Amphetamines and anorexic agents These drugs have potential for causing dependence, hypertension, angina, and myocardial infarction. Long-term use of full-dosage, longer half-life, Have the potential to produce GI bleeding, renal failure, high blood Non-COX-selective NSAIDs: naproxen pressure, and heart failure. (Naprosyn, Avaprox, and Aleve), oxaprozin
(Daypro), and piroxicam (Feldene)

Daily fluoxetine (Prozac)
Long half-life of drug and risk of producing excessive CNS stimulation, sleep disturbances, and increasing agitation. Safer alternatives exist. Long-term use of stimulant laxatives: bisacodyl May exacerbate bowel dysfunction. (Dulcolax), cascara sagrada, and Neoloid
except in the presence of opiate analgesic use Amiodarone (Cordarone)
Associated with QT interval problems and risk of provoking torsades de pointes. Lack of efficacy in older adults. Orphenadrine (Norflex)
Causes more sedation and anticholinergic adverse effects than safer Guanethidine (Ismelin)
May cause orthostatic hypotension. Safer alternatives exist. Guanadrel (Hylorel)
May cause orthostatic hypotension. Cyclandelate (Cyclospasmol) Lack
Isoxsurpine (Vasodilan) Lack
Nitrofurantoin (Macrodantin)
Potential for renal impairment. Safer alternatives available. Doxazosin (Cardura)
Potential for hypotension, dry mouth, and urinary problems. BEERS CRITERIA
Methyltestosterone (Android, Virilon, and
Potential for prostatic hypertrophy and cardiac problems. Testrad)
Thioridazine (Mellaril)
Greater potential for CNS and extrapyramidal adverse effects. Mesoridazine (Serentil)
CNS and extrapyramidal adverse effects. Short acting nifedipine (Procardia and Adalat) Potential for hypotension and constipation.
Clonidine (Catapres)
Potential for orthostatic hypotension and CNS adverse effects. Potential for aspiration and adverse effects. Safer alternatives Cimetidine (Tagamet)
CNS adverse effects including confusion. Ethacrynic acid (Edecrin)
Potential for hypertension and fluid imbalances. Safer alternatives Desiccated thyroid Concerns about cardiac effects. Safer alternatives available. Amphetamines (excluding methylphenidate CNS stimulant adverse effects. hydrochloride and anorexics) Estrogens only (oral) Evidence of the carcinogenic (breast and endometrial cancer) potential of these agents and lack of cardioprotective effect in older Abbreviations: CNS, central nervous system; COX, cyclooxygenase; GI, gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs; SIADH, syndrome of inappropriate antidiuretic hormone secretion Used with Permission References: Fick, DM, Cooper, JW, Wade, WE, Waller, JL, Maclean, JR, and Beers, MH. (2003) Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Arch Intern Med; 163: 2716-2724. (including correction note published Arch Intern Med 164:298.) The Medicare Quality Improvement Organization for Pennsylvania
OASIS ANSWERS, Inc. 2005 This material was prepared by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization for Pennsylvania, under contract with the Centers for Medicare & Medicaid Services (CMS). The views presented do not necessarily reflect those of CMS. Publication number 7SOW-PA-HH05.135 MEDICATION COMPLIANCE AIDS – SELECTION CRITERIA
Purpose: To assist in appropriate selection of medication compliance aids, based on identified patient skills
and/or deficits.

Candidates for independent medication management with compliance aids (M0780 response "0") should be able
to physically access medications (in their specific environment), sequence a two to three step process, and physically take (i.e., swallow) the medication.
Candidates for assisted medication management with compliance aids (M0780 response "1") should be able to
participate in taking (i.e., swallowing) oral medications with assistance, cueing, or compliance aid set up.
Skills patient must have to use aid
· Adequate vision
(text only)
· Able to read
· Able to recognize and monitor time
· Able to match written word to time,
drug, and task.
· Adequate vision
(illustrated drug + time)
· Able to read OR
· Able to match word, picture, or pill
· Able to match written word or
picture to # of pills and time of day · Able to monitor time.
· Adequate vision and fine motor skills
· Able to read OR
· Able to match word or picture on
box to day of week, time of · Able to monitor time of day.
· Adequate vision and fine motor skills
(i.e., blister packs)
· Able to read OR
· Able to match word or picture on
pack to # of pills and time · Able to monitor time.
· Adequate hearing to recognize
auditory alarm OR · Adequate vision and access to
recognize visual cue · Able to match alarm to drug
· Able to access and take drugs once
· May require patient to initiate
· Adequate hearing to detect
· Able to match spoken word to
· Message length/complexity must be
within patient's processing capacity (< 5 words, > 5 words, 2-step · Able to access and take drug once
· Adequate phone access & use
(auditory or adapted means) · Able to match instruction to drug
· Message length/complexity must be
within patient's processing capacity · Able to access and take drug once
· Adequate hearing to recognize
auditory alarm OR · Adequate vision and access to
recognize visual cue · Able to match alarm to task
· Able to access and take drugs once
References:Atkin, PA, Ogle, SJ. Issues of Medication Compliance and the Elderly. Adverse Drug Reactions & Toxicology Review, (1996) 15, 109-118.
Cook, PF. Methods for Assessing Medication Compliance: Research Summary (2001), www.scriptassistllc.com, last accessed 02/04/04Guerette, P, Nakai, R., The Right Prescription. TeamRehab Report, Page 21-23, (1993), www.wheelchairnet.org, last accessed 02/03/04.
www.epill.com last accessed 02/05/04www.lifeclinic.com last accessed 02/05/04 The Medicare Quality Improvement Organization for Pennsylvania
Medication Compliance Aids – Selection Criteria "Best Practices for Improvement in Management of Oral Medications" OASIS ANSWERS, Inc. 2005 This material was developed by Linda Krulish, PT, MHS, and Rebecca Skrine, MS, CCC-SLP, COS-C, CHCE, and distributed by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization for Pennsylvania, under contract with the Centers for Medicare & Medicaid Services (CMS). The views presented do not necessarily reflect those of CMS. Publication number 7SOW-PA-HH05.125 ORAL MEDICATIONS - CARE PLANNING TOOL
Selection Criteria by OASIS Level
Purpose: To assist in selection of interventions to improve management of oral medications based on the
initial patient status on M0780.

FOR M0780 OUTCOME INTERVAL "2" "1"
Barrier(s): Problem(s): Care Planning/Intervention(s):
Pain results in the need for medications Referral to RN/PT/OT to be administered by someone else.
· pain management interventions
Cognitive impairment prevents patient Referral to OT/SLP from taking medication independently · task analysis and simplification
even with set up, diary, or reminders.
· compensatory memory strategies
· sequencing strategies
Knowledge deficit prevents patient · environmental modifications to improve organization
from taking medication independently and accessibility even with set up, diary, or reminders.
· evaluation for selection of medication compliance aids.
Referral to RN
· medication teaching
· implement compliance aid
· simplify drug regime.
¾ MEDICATION COMPLIANCE AIDS –
¾ MEDICATION REGIMEN
¾ MEDICATION TEACHING STRATEGIES
Motor impairment prevents patient Referral to PT/OT from taking medication unless · motor task simplification
administered by someone else.
· evaluation for selection of medication compliance aids
· environmental modifications to reduce barriers
Visual impairment prevents patient · fine motor training
from independently taking medication · strength training.
unless administered by someone else.
Coordination with dispensing pharmacy for packaging Dysphagia prevents safe ingestion of oral medications unless administered by someone else.
Environmental modifications to improve patient's ability to visually recognize medications or to recognize medications Environmental barrier prevents patient using other means from being able to access medications, requiring administration by someone Referral to SLP for dysphagia therapy Environmental modifications to improve access to medications and necessary supplies for independent ¾ MEDICATION COMPLIANCE AIDS –
FOR M0780 OUTCOME INTERVAL "1" "0"
Barrier(s): Problem(s): Care Planning/Intervention(s):
Pain results in the need for someone to Referral to RN/PT/OT assist with medication administration.
· pain management interventions
Cognitive impairment or depression Referral to psych nursing/OT
· interventions to improve depression/effects
affecting motivation prevents patient from taking correct medications and Referral to OT/SLP proper dosages at correct times unless · task simplification
reminded or otherwise assisted with · compensatory memory strategies
compliance aid set-up/management.
· establish medication schedule around daily routines
· evaluate for internalization of reminder strategies
· evaluate for medication compliance aids
Cognitive impairment results in · environmental modifications to improve organization
ineffective use of compensatory and accessibility and to reduce barriers techniques or strategies (i.e. use of · sequencing strategies.
compliance aids), without reminders or Referral to RN
· medication teaching
· implement compliance aid
Knowledge deficit prevents patient from · simplify drug regime.
taking medication independently without set up, diary, or reminders.
¾ MEDICATION COMPLIANCE AIDS –
¾ MEDICATION REGIMEN
¾ MEDICATION TEACHING STRATEGIES
Motor impairment prevents patient from Referral to PT/OT taking medication without assistance.
· motor task simplification
· evaluation for selection of medication compliance aids
Visual impairment prevents patient from · environmental modifications to reduce barriers
taking medications without assistance.
· fine motor training
· strength training.
Environmental barrier prevents patient Coordination with dispensing pharmacy for packaging from being able to access medications, requiring assistance with set up or Environmental modifications to improve patient's ability to visually recognize medications or to recognize Dysphagia prevents safe ingestion of medications using other means oral medications without assistance.
Referral to SLP for dysphagia therapy Environmental modifications to improve access to medications and necessary supplies for independent ¾ MEDICATION COMPLIANCE AIDS –
The Medicare Quality Improvement Organization for Pennsylvania
Oral Meds – Care Planning Tool – Selection Criteria by OASIS Level "Best Practices for Improvement in Management of Oral Medications" OASIS ANSWERS, Inc. - 2005 This material was developed by Linda Krulish, PT, MHS, and Stephanie Mello Gaskell, MS, MBA, RN, COS-C, and distributed by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization for Pennsylvania, under contract with the Centers for Medicare & Medicaid Services (CMS). The views presented do not necessarily reflect those of CMS. Publication number 7SOW-PA-HH05.125

Source: http://www.smcfallprevention.org/index.php/download_file/view/93/113/

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The impact of climate change on aquatic risk from agricultural pesticides Nikolinka G. Koleva a,b,* , Uwe A. Schneider a a Research unit Sustainability and Global Change, Hamburg University and Centre for Marine and Atmospheric Science, Hamburg, Germany b International Max-Planck Research School for Maritime Affairs, Hamburg, Germany *Corresponding author: Research unit Sustainability and Global Change, Hamburg University and Centre for Marine and Atmospheric Science, Bundesstrasse 55, 20146 Hamburg, Germany, nikolinka.genova@zmaw.deNikolinka G. Koleva, Uwe A. Schneider

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Using care pathways to improve health systems Care pathways enable health systems (and other health care organizations) to make evidence-based decisions about where to focus improvement efforts. Olivia Cavlan, MD; One of the core missions of any health care for more severely ill children, and palliative Penny Dash, MD;