Nursing project tackles overmedication at Indiana nursing homes

Serving as a nurse for several Midwest nursing homes, Kathleen Abrahamson saw firsthand the challenges of providing quality care and helping residents manage their many daily prescriptions. Today, as a leading Purdue University College of Health and Human Sciences nursing professor and researcher, Abrahamson is tackling that same issue, partnering with nursing homes across Indiana.

That has occurred through a two-year, $600,000 Indiana State Department of Health project, officially named the Indiana Safer Medication Administration Regimens and Treatments campaign, or SMART. Collaborating with two statewide quality organizations, the project is touching residents at more than 20 Indiana nursing home facilities. A primary goal: To help them address the growing problem surrounding medication administration, particularly for patients with prescriptions for 10 or more drugs to be taken daily, known as “polypharmacy.”

“In terms of polypharmacy and reducing polypharmacy, it is a problem that touches many areas of health care,” says Abrahamson, whose team wrapped up the SMART project in April 2018. “It’s an economic problem, it’s a health outcomes problem, it’s a process problem. When people have to take 13 medications, it takes a long time. It decreases quality of life. We believed that if we could tackle this problem, it would have a significant impact across the board in terms of quality of care.”

Green House Cottages of Carmel, partnering with Purdue on SMART, examined the number of medications used by patients and their daily costs, as well as health care utilization, with a goal to reduce antipsychotic medications for its long-stay patients, says Green House executive director Gina Couch. Green House consists of six cottages, each with 12 private suites. The cottages include a family-style hearth room, open kitchen and dining areas.

“Starting at our campus in September 2017, we have been able to successfully reduce our antipsychotic medications from 38 percent to 20 percent,” Couch says. “We continue to work toward transforming long-term care in the state of Indiana as we combine caring, living and thriving to create a real-home environment for our elders. I can’t thank Dr. Abrahamson and Purdue School of Nursing enough for working alongside long-term care facilities to better the quality of life for our elders.”

The problem is real, particularly in Indiana. Studies show that 25 percent of adults over age 45 in the Midwest use six or more medications daily. In nursing homes across the country, 40 percent of residents are taking nine or more medications daily, and Abrahamson says estimates show that Indiana exceeds that number.

Inappropriate medication overuse resulted in $1.3 billion in avoidable health care costs in 2012, and officials say those costs continue to rise. Beyond the financial repercussions, nursing home residents are exposed to greater fall risks, adverse drug interactions, heart failure, renal failure, liver failure, delirium, cognitive decline and the risk of poor medication management, she says.

“As a nursing home nurse for 11 years, I found that medications were often inappropriately ordered or unable to be administered correctly,” Abrahamson says. “If you have a patient that isn’t able to fully cooperate, the drug’s usefulness also can be decreased. There is a need for ongoing medication review as people age and become more debilitated, because some of the medications that they’re taking may no longer be appropriate.”

Through SMART, the Purdue researchers formed an academic detailing team and sought input from geriatricians and geriatric pharmacists with expertise and interest in nursing home care.
At the heart of the intervention, she says, is a direct physician-to-prescriber communication.

This face-to-face education of prescribers by trained health care professionals, typically pharmacists, physicians or nurses, builds on peer-to-peer, evidence-based, prescribing-decision discussions.

The nursing homes also tapped Purdue quality-improvement experts and systems engineers in Purdue Nursing and across campus to tackle not just deprescribing, but the processes surrounding medication administration within their facilities.

“Changes to these practices at Indiana nursing homes could improve the lives and protect the safety of vulnerable residents, while allowing individuals and public funding mechanisms such as Medicaid to save money,” Abrahamson says.

Nursing doctoral student Yun “Karen” Cai, project manager for SMART, says she has had the opportunity to communicate with statewide nursing facilities, conduct site visits and draw on the expertise of researchers across many disciplines.

“I am a first-year doctoral student interested in nursing home research, and these experiences have prepared me for developing my own research trajectory,” Cai says. “Dr. Abrahamson, the superstar in nursing home research, is such a great role model. She has been an outstanding mentor to me.”