Improved Administration of Prescription Drugs in Domiciliary Care Facilities

  • Date: Jan 01 1987
  • Policy Number: 8733PP

Key Words: Long Term Care, Prescription Drugs

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.

In planning current and future strategies for improving drug therapy management in DCFs, the objectives need to be matched with a comprehensive research agenda, educational efforts, resource coordination, and advocacy programs.

  • A resources coordination strategy should be developed so that communication between caregivers, physicians, pharmacists, and drug regimen reviewers will be improved. DCFs should be encouraged to identify a single health care provider as the resource to assist in institutional problems, while maintaining the residents' rights to choose their own sources of care. Secondly, coordination of the agencies involved in reimbursing, controlling, and licensing these facilities should take place. Integration of the state and federal agencies involved in regulating care for the residents in DCFs appears necessary, and successful models of local coordination between health and social service agencies should be identified.
  • An educational strategy should be developed and targeted at lay caregivers including managers, supervisors, and attendants. The development of the continuing education efforts can be based on experience obtained in other types of long-term care facilities but must consider the specific nature of DCFs, and be in response to the special needs of the caregivers. A few states (e.g., North Carolina) have implemented mandatory continuing education requirements for the managers of DCFs. However, development of educational programs and materials has not yet materialized.
  • A comprehensive research agenda should incorporate an inventory of the available facilities — the organizational, management and personnel resources — available for drug administrtion. Resident population statistics are lacking, including case mix assessments and data on qualitative and quantitative drug use. Sociodemographic and other background information on caregivers, supervisors, and managers, and their qualifications, would provide important information on the target populations for educational intervention. Assessment of communication patterns between physicians, caregivers, and pharmacists will provide information about the discontinuities in drug therapy management. Another research question deals with the source of admission of residents of these facilities and their discharge locations. For example, in some states deinstitutionalized mental patients are increasingly being placed in DCFs, creating additional demands for careful management of antipsychotic drugs. However relevant this information may be, it is available neither to health care researchers nor policymakers at this time.

IV. Desired Actions and Recommendations

  • APHA should foster the formulation of model licensure requirements for DCFs;
  • APHA should encourage federal agencies, such as the National Center for Health Services Research and Technology Assessment, the National Institute on Aging, the National Institute of Mental Health, and the Health Care Financing Administration to recognize the role of DCFs in long-term care and promote the development of interventions to improve the pharmaceutical care of residents of these facilities; and
  • APHA should further the development of a knowledge base specific for DCFs and encourage the inclusion in gerontology curricula for health care practitioners and those in health departments and social service agencies that have overnight responsibilities for monitoring DCF institutions.

V. Methods of Implementation

The issues presented in the position paper will be distributed to the National Association of Residential Care Facilities and the National Association of Homes for the Aged, American Society of Consultant Pharmacists, key federal agencies and congressional committees, the National Council on Aging, and National Council on Patient Education. Letters will be written to all state associations for DCFs, state councils on aging, and gerontology programs sponsored by the public health agencies. The cost of these actions for the APHA will be limited to the administrative costs of distributing the information to key associations and agencies directly or indirectly involved in domiciliary care, the cost to be determined by APHA.

References:

  1. Oltman RM: The small group home: needed option for the poor elderly. Home Health Care Serv 1981;2(3):59-66.
  2. Dittmar ND, Smith GP, Bell JC, Jones CBC, Manzanaus DL: Board and care for the elderly and mentally disabled populations, final report abstract. Denver, CO: Denver Research Institute, Social Systems Research and Evaluation Division, University of Denver, March 1983.
  3. Palmer HC: Domiciliary care: a semantic tangle. In: Vogel RJ, Palmer HC: Long-Term Care: Perspective from Research and Demonstrations. Washington, DC: Health Care Financing Administration, USDHHS, 1983.
  4. Scanlon W, Sulvetta M: The supply of institutional long-term care: Descriptive analysis of its growth and current state. Washington, DC: Urban Institute (Work paper) 1466-1413 (rev), April 1983.
  5. Sherwood S, Morris JN: The Pennsylvania domiciliary care experiment: I. Impact on quality of life. Am J Public Health 1983;73:646-653.
  6. Bradshaw BR, Vonderhaar WP, Keeney VT, Tyler LS, Harris S: Community-based residential care for the minimally impaired elderly: A survey analysis. J Am Geriatr Soc 1976;33:423-429.
  7. Kane RL, Kane RA, Arnold SB: Prevention and the elderly: Risk factors. Health Serv Res 1985;19:945-1006.
  8. Hollister LE: General principles of treating the elderly with drugs. In: Jarvik LF, Greenblatt DJ, Harman D (eds): Clinical Pharmacology and the Aged Patient. New York: Raven Press, 1981.
  9. Vener AM, Krupka LR, Climo JJ: Drug usage and health characteristics in noninstitutional retired persons. J Am Geriatr Soc 1979;27(2):83-90.
  10. Kalchthaler T, Coccaro E, Lichtiger S: Incidence of polypharmacy in a long-term care facility. J Am Geriatr Soc 1977;25:308-313.
  11. Budden F: Adverse reactions in long-term care facility residents. J Am Geriatr Soc 1985;33:449-450.