Managing medications in assisted living.
Medication management in the assisted living facility can differ considerably from that traditionally found in the nursing home. Acuity of nursing home residents generally dictates complex drug regimens, frequent revisions in prescriptions and ongoing evaluation for effectiveness. Residents are significantly compromised physically and often mentally, thereby limiting their ability to safely self-administer medications.
By contrast, the assisted living resident is a medically stable individual requiring only minimal to moderate support with activities of daily living and monitoring of health status. Medication orders are constant month to month, with virtually no changes in type, dosage or frequency. These factors are particularly conducive to successful resident management of medications.
The assisted living philosophy is one of individualizing and maximizing consumer independence, choice, privacy and dignity. When the assisted living resident enters the facility, he/she does so with the expectation of receiving only those accommodations and services necessary to manage the medical condition or disability which prohibits residing in the home environment.
Because the resident may exhibit functional limitations, there is a tendency on the part of nursing staff to overlook the strengths still remaining. This is especially true with regard to self-administration of medication. Nurses have long considered medications their responsibility and are particularly reluctant to relinquish control. This thinking must change for the assisted living setting.
Our approach to this in two assisted living facilities we service is the SMARTT Program - Self Medication Awareness and Responsibility Through Training. It offers education at three levels: residents, licensed nurses and nursing assistants.
Before a resident can participate in the SMARTT Program, he/she must first demonstrate competency (mental and physical) in self-administration of medications, and the ability to remain compliant with prescribed drug regimens. This is accomplished through an assessment conducted by the nurse which focuses on such issues as dexterity, comprehension, recall and visual acuity.
Once the nurse determines the resident is suitable for the program, an order for self-administration is obtained from the attending physician. The resident education process then begins.
For the resident who does not successfully pass the assessment, medications are delivered in the traditional manner and a reassessment is scheduled for another time. Everyone is offered multiple opportunities to participate in the program.
Empowering the Resident
Residents in the SMARTT Program learn to identify their respective medications, their purpose and the correct dosage. Administration basics, e.g., reading labels, "breaking into" bubble packages, managing ready-to-use medication sets, and opening child-proof bottles, are provided to promote self-esteem and independence.
Additional instruction focuses on safety. Residents are cautioned against "doctor shopping," as occurs in community settings, with elderly patients going from doctor to doctor and ending up with "pharmaceutical kitchen cabinets." Warning signs of drug interactions in the elderly are discussed and residents are encouraged to report any situations to the nurse.
As a continuing service, monthly "Meet the Pharmacist" meetings are conducted where residents can voice concerns or ask questions about specific medications and receive appropriate guidance.
Responsibility of the Nurse
Nurses, for their part, are the gate-keepers for the SMARTT Program. Determining appropriateness of self-administration is a nursing process which requires a "judgment call" based on the nurse's education and experience in caring for the geriatric population. To accomplish this, the Program incorporates the above-mentioned assessment, including a mini-mental status exam to rule out cognitive impairment.
The assessment is applicable to oral medications, inhalers, patches and topical ointments. More complicated routes of administration, such as suppositories and injections, are generally the responsibility of the nurse unless the resident has demonstrated capability for these. True, some residents may have self-administered insulin for many years, but it must be determined that they still have the dexterity to draw up the insulin and adequate vision to read the units.
Instructional materials are made available as backup to the initial self-administration program provided by the pharmacy. If the nurse observes any decline in the resident's ability to self-administer, a teaching plan can be quickly implemented to reinforce safe, accurate medication management. Simple reminders about opening packages, medication times, etc., are often enough to keep the resident compliant.
Quality assurance monitoring is an important nursing function in the SMARTT Program. Nurses perform routine audits of the medication administration record (MAR) of each resident in the program to identify any omissions. Obvious problems are discussed with the resident to determine why the medications were not taken.
Since nursing assistants also actively participate in the SMARTT Program, their performance is subject to quality observations by the nurses for adherence to medication-assistance policies and procedures. The results of these are shared with the nursing assistants.
The nurses' overall responsibility for administration of medication as a licensed professional remains the same as for any setting: receiving medication orders, checking for allergies, ordering medications from the pharmacy, validating correctness of labels, assessing effectiveness, documenting and reporting adverse reactions, and policing the quality assurance component of administration - in short, ensuring that the right medication is given at the right time to the right individual.
Role of the Nursing Assistant
The ability of the resident to succeed in the SMARTT Program often depends upon receiving supportive assistance from another person. In the assisted living facility, the nursing assistant is a logical choice for this role.
It is extremely important to distinguish between assistance versus administration. In Ohio, nursing assistants are permitted to assist a resident by reminding him / her to take medications, watching to make sure the resident follows package directions, verifying that the name on the prescription label matches the resident's, retrieving medications from the storage area, reading label directions to the resident, and opening packages and removing medications per the resident's request. The operative word here is "request." Nursing assistants are not to intervene in self-administration unless requested by the resident or the nurse.
Selection of nursing assistants for the program is at the discretion of the facility. The number should be proportionate to those residents requiring extra help with self-administration. The focus of nursing assistant education is twofold: 1) learning the skills necessary to fulfill the assistance elements of the program; and 2) recognizing potential medication-related problems in the elderly.
Much time is spent with nursing assistants on practicing reading labels, opening a variety of delivery systems and becoming acquainted with the MAR. Special attention is given to basic infection control practices. The first time a nursing assistant is assigned to facilitate self-administration, a pharmacy representative (RN consultant or pharmacist) accompanies the individual to ensure proper procedures are followed.
An additional benefit of utilizing nursing assistants is having frontline "eyes and ears" for observing and reporting. They are expected to watch for apparent drug side effects, changes in physical condition or noncompliance with medication regimens. The second portion of their training, therefore, prepares the nursing assistants to be educated observers. Topics discussed include normal versus abnormal changes in aging, risk factors for geriatric side effects and how to effectively report observations to the nurse.
Aside from education and training, there are several other issues that arise in the overall management of assisted living medication programs. Knowledge of state pharmacy laws is very important. Such issues as storage regulations and dispensing requirements could alter the nature of the program.
Assisted living residents in Ohio are permitted to keep medications in their rooms, provided that secure arrangements are used when necessary. For instance, a cognitively impaired resident's roommate may pose a risk of accidental access to another's medication, thus requiring a locked storage system. Unfortunately, not all security containers are practical for the elderly and, therefore, require personal assistance that otherwise might not be needed.
Packaging policies vary from state to state. Some systems may be too cumbersome for many residents to handle or too informal to permit effective quality assurance tracking. Presently, medications can be pre-filled in so-called Medi-Sets, Med-Pass Sets or Seven-Day Sets. Residents also have the option to approach the med cart to extract their own medications under supervision if they do not wish to store medications in their room.
Soon our SMARTT Program will incorporate a new medication packaging method in which all the drugs a resident requires at a given hour of the day are combined into a single dispensing pouch. The resident will open only one package to take all of the scheduled 9:00 AM's, for example. We are hoping this will enhance resident self-administration capabilities and self-esteem while improving quality assurance follow-up for the nurse.
As with any new idea, there are those who do not embrace change readily. Assisted living nursing staff are no different. Overcoming hurdles in traditional thinking about eldercare and nursing responsibilities are challenges to successful implementation. A firm belief in resident empowerment and administrative support to that end are essential to facilitating this type of program.
The only significant problem confronting the success of the SMARTT Program is one that faces the nursing home industry in general - nursing assistant turnover. Because many residents in the program do require some assistance to self-administer, the presence of qualified staff is crucial. Retraining of nursing assistants is an ongoing process and a commitment that our pharmacy has made to ensure the success of the program in our participating facilities.
We believe that a self-administration initiative, such as the SMARTT program, can serve as an effective marketing tool, setting the facility apart from the competition. By promoting functional independence, the facility says to a potential client, "We care about you and your need to feel useful and in control. We acknowledge your limitations while respecting your abilities."
When residents feel better about themselves, so do staff. The SMARTT program gives structure and accountability to an otherwise vague, undefined concept. Nurses have tools to use and guidelines to follow. Nursing assistants demonstrate increased pride in their work, coupled with a vested interest in outcomes.
Economically, increased efficiency in staff utilization translates to dollars saved. Traditional medication-pass time for nurses is significantly reduced, allowing them to assume other duties; less expensive manpower facilitates the self-administration process.
Undoubtedly, the biggest winner is the resident. A self-administration program improves residents' perceptions of medication usage and provides delivery options appropriate to their individual needs. Residents have available to them continuous information sources regarding their drugs, as well as qualified persons to assist them. Most important, these proactive efforts ease the resident's transition from home to a new environment.
Our assisted living facilities have embraced the SMARTT Program wholeheartedly. Three new facilities have recently come "on line" and are anxious to start the program because of the potential it holds for enhanced resident autonomy and subsequent reduced nursing time. By all accounts, our residents do feel more involved in their own health care which, in turn, fosters autonomy within a safe environment. Staff, for the most part, express increasing confidence about self-administration of medication and are enjoying less pressure from their job duties, even in this relatively low-maintenance setting.
Jo Donovan, RN, BSN, is Director of Educational Services, Skilled Care Pharmacy, Mason, Ohio. For more information, call 1-800-334-1624.