Archived APHA Policy Statement

I. Statement of the Problem

The impact of recent and anticipated demographic changes on the health care requirements of the impaired elderly will assume increasing economic and social importance for the remainder of this century and well into the next. An aging and increasingly vulnerable population combined with a diminishing availability of informal family supports will probably result in increased demand for and use of long-term care facilities. It is not apparent that this demand will be translated into increased supply of "health care" type facilities. Still learning from the rapid increase of nursing homes in the 1960s and 1970s, states will instead attempt to promote "low technology" options like "board and care" or "family home" facilities.¹ The use of such facilities is likely to increase.² This is due not only to the high cost of nursing home care borne by state governments, but also because states can shift the costs to the federal government by placing persons in domiciliary care with 100 per cent federal SSI (supplemental security income) payments. In a recent report prepared for the US Department of Health and Human Services (DHHS),³ the need for additional supervised community residential facilities for the elderly was identified. It is estimated that 350,000 elderly are housed in these facilities at this time and that the number of persons placed in domiciliary care facilities will increase in the coming years.⁴

Domiciliary care facilities (DCFs) are essentially quasi-health care institutions, staffed by lay persons. This type of facility is referred to in the literature under various names (e.g., congregate housing, board and care homes, sheltered care, family care homes, homes for adults, group homes, and rest homes). These facilities all serve a common purpose by providing room, board, and protective oversight for their residents. Protective care does not encompass nursing care but includes functions such as supervising resident activities, providing personal assistance, administering medication, and obtaining medical care for the resident.^5,6

Elderly residents of DCFs are predisposed to experience therapeutic problems with drugs not only because of the biological effects of aging, but also because of their high levels of drug consumption and polypharmacy. The elderly have a "narrow theapeutic window" because the range between dosage levels for benefits and toxicity effects often narrows for older patients.⁷ The aging process results in physiological changes which, in time, affect the absorption, distribution, and metabolism of medications.⁸ As a result, the response of elderly patients to drug therapy is often unpredictable, and requires careful drug prescribing and dosing, administration, and monitoring;

Moreover, the elderly show a high prevalence of chronic illness and physical impairment,⁹ resulting in substantial drug utilization and polypharmacy.¹⁰ Among residents of North Carolina DCFs taking at least one prescribeed medication, an average of 5.8 drugs per patient are concurrently prescribed. Because concurrent consumption of several medications increases the probability of adverse drug reactions, it is not surprising that studies have documented the high frequency of adverse drug effects in the elderly. A 26 per cent incidence of adverse drug reactions in residents of DCFs admitted to an acute geriatric ward was observed in a recent study.¹¹ The frequent use of powerful psychoactive drugs (e.g., neuroleptics) among these residents also requires staff to be attentive to possible serious adverse effects of these drugs.

A documented need exists for a program of research and the development of relevant education and technical assistance programs for personnel working in DCFs and/or providing care for residents. Caregivers in DCFs often have limited education and no medical background.^5,6 Lay caregivers are thus placed in a double bind by society: explicitly prohibited from being identified as health care providers, yet expected to carry out and be held accountable for the performance of fairly complex health-related tasks and responsibilities. To avoid medical or pharmaceutical responsibilities, caregivers are required to coordinate physician, pharmacist, family, and resident information, communication, and interaction. These demands require that caregivers have substantial familiarity with medical decision-making without significant participation, Further, in many states the legal responsibility for medication administration is assigned to the caregiver. Errors in medication administration and the failure to recognize important adverse drug effects are likely to occur in the absence of special efforts to prevent them.

II. Purpose

The purpose of this position paper is to: 1) propose a strategy to assure the quality of care in DCFs, particularly pharmaceutical care, with due consideration of the managerial and fiscal resources available; and 2) set priorities for research to improve drug prescribing, administration within the limits allowed by state law, and monitoring in domiciliary care. Although a large amount of energy and research dollars has been spent on research and on instituting quality assurance programs in long-term care facilities, such as skilled and intermediate nursing homes, DCFs have not received the attention deserved relative to their importance in the spectrum of long-term care.

III. Objectives

The drug therapy management process in DCFs can be conceptualized as a circular flow of information and control involving the prescribing physician, the dispensing pharmacist, the DCF caregiver, and the drug regimen reviewer—generally a consulting pharmacist, physician, or nurse. The communication between physician and pharmacist takes place largely through the prescription. The medication recording and administration procedures in the DCF should contain sufficient information for the caregiver to administer the medication and for the drug regimen reviewer to perform periodic review on each patient. Finally, the drug regimen review recommendations should provide feedback to the prescribing physician. If correct information is available at each phase and if that information and control are correctly transferred, then the entire system should function optimally.

The objective of this initiative is to institutionalize research and programs that increase the quality of pharmaceutical care in DCFs. Intermediate objectives are to:

1. decrease the number of medication administration errors made by caregivers;
2. increase recognition and follow-up by caregivers of adverse drug effects;
3. improve the quality of drug regimen review in DCFs or to implement a program of drug regimen review in domiciliary care;
4. improve prescribing practices of physicians serving residents of DCFs; and
5. improve the communication between the health care providers and the caregivers in these facilities.