Managing Medication Risks (Community Services)
Resthaven Marion Community Services
Resthaven Onkaparinga Community Services
Rest haven Community Respite Services
Resthaven Limestone Coast Community Services
Resthaven Murray Bridge Community Services
Resthaven Riverland Community Services
Residential and Home Care - Metropolitan, 80 + beds
Workforce, Clinical care / medication management, Enablement
About the program
Resthaven Incorporated provides services to over 8000 older people per year living in the community, some in rural areas. A major service that the organisation provides is supporting people to safely take their medication: either by supporting self-management or self-administration, or by staff administering medicines to the person.
The organisation has identified this service area as being one of the highest risk activities, due to the nature of community services (in home environments), the direct involvement of carers, the varied skills/professions of the workforce, and the number of program standards, guidelines and legislative requirements that must be considered.
The organisation’s learning over a number of years, including during a funded workforce project, Safe Medication Use in the Community, provides us with an opportunity to provide leadership to the wider aged care sector. Our innovative model is focused on reablement and empowerment of the consumer to self-manage medicines for as long as possible; workforce skill development, with a good understanding of the roles of clinical and non-clinical workers in the medication management process; and co-production of systemic changes, in collaboration with consumers and staff.
Since the main medication focused project finished in 2014, the organisation has continued to consolidate the training, systems, processes and tools that were products of the project. The organisation has robust systems for ongoing monitoring of client safety in relation to medication management systems, including audits; reporting, collation and analysis of medication incidents, discussion at the organisation’s medication advisory committee, and role-specific training/competency assessments for workers.
What we did
The broad and stated aim of the Safe Medication Use in the Community project was to address the issue of an increasing number of older people living in the community who are using medication, with a limited workforce to meet their service and support needs.
The project was informed by a survey of clients receiving community services (with 424 (68%) respondents) who provided valuable feedback in co-design of the project. Approximately 70% of respondents said they self-managed their medicines (sometimes with support of family) and 30% said they receive assistance by paid workers to take their medicines. In addition, 48% stated that they take 5-10 medicines and 24% take more than 10 medicines.
The project team’s plan included a Project Logic model that detailed the key objectives, inputs, outputs and outcomes for the project, and an evaluation plan that described questions, data sources, methodologies and indicators using Goal Attainment Scaling.
The project design included:
- Competency role design: Develop/articulate a workforce model that is effective, efficient, sustainable and competent with assisting clients with medication
- Better balance of roles: Optimise client capacity to self-manage medication for an optimal length of time
- Partnering across the care continuum: Facilitate partnerships and communication pathways across the care continuum
- Building leadership for change: Evaluate the impact of the workforce model and disseminate the findings, both positive and negative
- System enablers: Improve systems with a comprehensive suite of system enablers.
The project involved six community service sites within the organisation. The functions, practices and workforce competencies required across the client service journey were identified, starting with the client’s practices with respect to safe medicines use. This model was informed by the client survey. The information provided the impetus to develop a comprehensive suite of system enablers that addressed identified issues and gaps associated with staff competencies.
To support system change, the following were developed and implemented in partnership with workers, clients and stakeholders:
- Development of assessment and planning tools for medication management that were relevant and suited to providing services in the community, optimised and enabled client self-management, and adhered to professional standards/guidelines and legislation
- Refining policy, procedure and work instructions
- Developing and implementing training for the workforce aligned with the identified workforce competencies (96% of Home Support Workers, 98% of Coordinators and Registered Nurses participated in a total of 44 training sessions)
- Trialling devices to support self-management and developing additional tools in partnership with clients to support self-management of medications (booklet, wallet card).
Since completion of the project, the organisation has continued with a focus on embedding a culture of client reablement and self-management. This included roll-out of systems/training across the organisation to ensure staff maintain skill/competency. The organisation implemented a robust monitoring system including medication system auditing, medication incident reporting and collation/analysis of results, and an ongoing focus on addressing identified issues to build increased safety for older people who are using medications.
Why we did it
The organisation has identified that supporting older people living in the community with safe medication use is one of the highest risk activities for community aged care. Professional standards, local and federal legislation and regulations, and differing requirements in funded program guidelines, all contribute to a significant complexity when developing systems to guide staff in their practice.
Chronic disease/health issues result in a greater number of older people living in the community who require assistance with managing their medication: research indicates over 60% of people aged over 75 reported they use five or more complementary or conventional medicines each day (Morgan et al, 2012).
The Consumers Health Forum of Australia (2011) reported adverse medication events in the community are common, with 30.4% of hospital admissions in older Australians associated with such events.
The organisation’s internal review of medication management in the community (2012) showed 45% of reported medication incidents were client/family errors, and some staff practice inconsistencies.
The Aged and Community Services Australia position paper on the Aged Care Workforce in Australia (2015) highlights medication management as a key skill issue to be considered and addressed in training, role development and innovation.
The organisation’s Safe Medication Use in the Community project (funded through Health Workforce Australia Aged Care Workforce Reform initiative), commenced in 2012. The project developed a workforce model to assist older people living in the community with medication, and optimised client capacity to self-manage medication. The organisation has continued to build on the learning/achievements of the project.
Who worked with us
The organisation consulted with consumers throughout the project: a large survey informed initial project development, and members of the organisation’s Community Advisory Groups provided feedback about consumer products developed to support increased empowerment in understanding and self-managing medicines.
The organisation involved three regional Medicare Locals in the project, with consistent representation on the project steering group. Pharmacists from Flinders Medical Centre, The Repatriation Hospital and a community pharmacist with a particular interest in the project provided advice, feedback and input into development of strategies. The Project Steering Group also included seven organisational representatives (Clinical Services, Workforce Development, Community Services).
In an attempt to capture, document and address issues associated with medication management the project team arranged four regional workshops in key locations, three rural and one metropolitan. The aim was to create direct communication pathways that facilitate safe medication use in the community and when transitioning in and out of hospital and provide an avenue to report medication incidents to the hospitals/primary health care agencies. There were 31 participants, including pharmacists, members of aged care assessment teams, practice managers/community nurses/discharge planners, and representatives of the organisation.
Potential improvement opportunities to support the older person with their medicines were discussed and action agreed, including:
- developing question prompts for older people to take to their doctor in relation to their medication
- promoting the benefits of the 75+ Health Assessments and Home Medicine Reviews for older people.
What we learned
The organisation has developed a workforce model that facilitates increased involvement of the non-clinical community coordinator in supporting client self-management of their medication. Clear guidelines are available to support staff to understand when a clinical nursing assessment related to medication is indicated.
Tangible results from the project included:
- Improved understanding of and confidence in the workforce model: staff surveys pre and post training showed an improvement in clarity about their scope of practice with respect to clients and their medicines (increase from 85% to 95%) and confidence with their skills (increase from 83% to 92%).
- Audit results of a sample of medication documentation pre and post implementation of the project indicated:
- Clear documentation on medication chart (increased from 66% to 88%)
- Non-clinical coordinators appropriately completing non-clinical component of medication assessments (nil were previously conducting assessments, to 90% of audited sample where relevant assessment conducted by Coordinator)
- Care plans included strategies to optimise client independence (increased from 40% to 90%)
- The number of support visits per client in the community decreased: on average the number of client visits per month decreased from 14 to 12 demonstrating a productivity gain of 15%.
A number of medication administration aids/devices were trialled in partnership with clients, to support self-management (e.g. dose administration aids, timers, dexterity aids). Stakeholders and 35 consumers provided direct input to developing a wallet card, that contains key questions to ask the person’s doctor, and a "Guide to using your medicine safely", a booklet containing key messages about managing medicines.
Feedback on these resources indicated that:
• 100% stated people would be better informed by reading the “guide”
• 94% stated the “guide” helped them to better understand how to manage their medicines.
Ten case studies were identified where a client who was previously being supported with medication administration by paid workers were now self-managing, due to improved assessment, new strategies, or use of some kind of physical aid/gadget. For example:
“Staff were providing daily visits to insert eye drops and prompt the client to take their medicines during the week, with family assisting on the weekend. Following an RN assessment and discussions with the client an eye dropper aid was introduced. The client successfully trialled the eye dropper and a timing device was implemented to remind the client to take their medicines in the morning. The client is now self-managing their medicines”.
The outputs of the project now embedded into the organisation’s systems include:
- A documented workforce model, based on the journey of the client, focused on supporting safe self-management of medicines
- Revised policy/procedure
- New assessments and care plans, colour-coded to assist staff to know when a non-clinical or clinical assessment is indicated
- Introduction of a standardised, evidence based medication chart into community services
- Training modules, matched to the new system, and regularly provided to all levels of staff
- A guide to support staff to better understand medication incident reporting.
Since the project completion, the organisation has committed to the systemic changes, with staff access to the new assessment tools, work instructions, training modules, and a culture of client enablement embedded in practice. The systems developed during the project, initially implemented at six community service sites, have been adopted across all 10 community service sites.
The organisation is committed to continually developing safe systems for older people in response to risks associated with mismanagement of medicines in the community. Monitoring processes include annual site specific medication audits of medication system, and staff compliance with policy and procedure. The audits are conducted by a trained internal auditor to provide consistency in audit methodology. Site specific issues are reported to the community site’s manager, who is required to implement responsive strategies and training where needed.
Analysis of incident data, (collected at times of medication audit), demonstrates a reduction in the number of incidents related to client/family error, from pre project (64%) to 2015 (50%). The main opportunity for improvement identified through the auditing process is the need for increased attention to induction of new staff in specific processes such as medication management.
In addition, medication incidents are reported, and information collated/analysed to identify trends and responsive actions. Issues are discussed at Medication Advisory Committee meetings. There has been an increase in awareness of the incident reporting system resulting in more medication issues being identified as incidents and reported through the system.
More information on the program:
Sue Mc Kechnie, email@example.com or phone (08) 8373 9141.