Assessing patient work system factors for medication management during transition of care among older adults: an observational study

Abstract

Objective: To develop and evaluate measures of patient work system factors in medication management that may be modifiable for improvement during the care transition from hospital to home among older adults.

Design, settings and participants: Measures were developed and evaluated in a multisite prospective observational study of older adults (≥65 years) discharged home from medical units of two US hospitals from August 2018 to July 2019.

Main measures: Patient work system factors for managing medications were assessed during hospital stays using six capacity indicators, four task indicators and three medication management practice indicators. Main outcomes were assessed at participants' homes approximately a week after discharge for (1) Medication discrepancies between the medications taken at home and those listed in the medical record, and (2) Patient experiences with new medication regimens.

Results: 274 of the 376 recruited participants completed home assessment (72.8%). Among capacity indicators, most older adults (80.6%) managed medications during transition without a caregiver, 41.2% expressed low self-efficacy in managing medications and 18.3% were not able to complete basic medication administration tasks. Among task indicators, more than half (57.7%) had more than 10 discharge medications and most (94.7%) had medication regimen changes. Having more than 10 discharge medications, more than two medication regimen changes and low self-efficacy in medication management increased the risk of feeling overwhelmed (OR 2.63, 95% CI 1.08 to 6.38, OR 3.16, 95% CI 1.29 to 7.74 and OR 2.56, 95% CI 1.25 to 5.26, respectively). Low transportation independence, not having a home caregiver, low medication administration skills and more than 10 discharge medications increased the risk of medication discrepancies (incidence rate ratio 1.39, 95% CI 1.01 to 1.91, incidence rate ratio 1.73, 95% CI 1.13 to 2.66, incidence rate ratio 1.99, 95% CI 1.37 to 2.89 and incidence rate ratio 1.91, 95% CI 1.24 to 2.93, respectively).

Conclusions: Patient work system factors could be assessed before discharge with indicators for increased risk of poor patient experience and medication discrepancies during older adults' care transition from hospital to home.

Keywords: Human factors; Medication safety; Transitions in care.

Figure 1.

Study flow. Home assessment was targeted within 1-2 weeks of hospital discharge.

Figure 2.

Incidence risk ratios (IRRs) for patient work system factors related to the number of medication discrepancies assessed at the study participant homes after discharge. MRCI: medication regimen complex index. Low med-admin skills: inability to complete all three medication self-management skill tests (reading sample medication labels, describing instructions on labels, and opening the bottles). Low self-efficacy: neutral or negative on responses to at least one item in short form of Self-Efficacy for Managing Chronic Conditions – Managing Medication and Treatment.[28]