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Longitudinal Care Plans: Still Siloed

by Matt Guldin | February 26, 2015


I have been doing a lot of work and research around the current state of care plans for an upcoming Insight report that will be out in March. Some of their limitations in current practice though have become glaringly apparent to me through a recent incident effecting my 99-year old grandmother.

Last March, my grandmother was admitted to a senior living facility on a full-time basis. As a part of her admission by PA state law, the facility was required to complete a Resident Assessment Support Plan (RASP) within 30 days of her admission. This document varies slightly from state-to-state but it is required by federal law for any patient admitted into a long-term care facility. It is a comprehensive care plan to assess the needs of the patient and incorporate the desires of both the patient and her family/legal guardians.

The form in PA is quite lengthy with several sections including one that has a support plan for medications. In my grandmother’s case, this is the where problems occurred. One of several medications that she receives is a 25 mg Fentanyl transdermal patch, a pain management medication used to treat moderate to severe chronic pain. It was to be applied by one of the facility’s LPN/RNs on her back between her shoulder blades. All of this information was captured in the RASP that was completed upon her intake in March 2014.

Awareness of the Problem
The problem with my grandmother’s medication was detected last month during his residence at the senior living facility. At my grandmother’s most recent visit with her chronic pain physician, he recommended that the dosing of her Fentanyl medication be increased from 25 mg to 37.5 mg. This was due to my grandmother’s continued issues with severe chronic pain. The chronic pain physician thought that the 25 mg dose was no longer effective and he wanted to increase the dosage to see if that would alleviate some of her pain.

The revised script was sent into the pharmacist who prepares the Fentanyl patches. He called the chronic pain physician’s office to let them know that my grandmother was not currently on any Fentanyl medication and this information was relayed to my mother and aunt.

At this point, my mother and aunt knew something was wrong. My grandmother was not receiving any Fentanyl medication, which was causing her severe issues with pain especially in her back and legs. When my mother came in and spoke with the LPN, the LPN looked up the medication information on the facility’s Catalyst medication administration system. The LPN confirmed that my grandmother was not currently receiving any Fentanyl medication. The LPN at the nursing deck just didn’t know why, nor was this change indicated on my grandmother’s RASP form in the medication section.

Seeking Answers
After this happened on a Friday, my mother scheduled a meeting with the Executive Director of the facility along with the LPN the following Monday. When they meet for an hour to get an explanation, my mother and aunt got this response:

  • The facility was not sure who initiated the request to withdraw my grandmother from the Fentanyl medication.
  • The facility asserted it had happened last spring in April when she had gone to her family physician for an appointment.
  • Executive Director presented the dispensing order from my grandmother’s family physician to discontinue the Fentanyl prescription.
  • The LPN insisted the pharmacist had contacted my grandmother’s chronic pain doctor’s office to let him know them know the Fentanyl prescription was being discontinued.

This answer did not satisfy either my mother or aunt. Over the next few days and after several inquiries by my mother and aunt to my grandmother’s family physician, her chronic pain physician, the pharmacist at the facility who prepared the Fentanyl medication, and the senior living facility where my grandmother resided, they finally found the answers they were seeking.

The Fentanyl prescription had last been filled in April 2014 and discontinued in May 2014. Every month, the Fentanyl prescription had to be reauthorized since it was a controlled narcotic. The LPN at the senior living facility was supposed to contact my grandmother’s chronic pain physician every month. Instead in late April 2014, the senior living facility LPN had erroneously reached out to my grandmother’s family physician instead of the prescribing physician – my grandmother’s chronic pain physician

During the late April 2014 call to my grandmother’s family physician’s office, the senior living facility LPN told them my grandmother was being irritated by the Fentanyl patch and was removing it when it was applied. The LPN recommended that the Fentanyl prescription be halted as a result. Following the LPN’s recommendation, my grandmother’s family physician wrote an order to stop dispensing the Fentanyl prescription. This was done despite the prescribing physician – my grandmother’s chronic pain physician – never be notified or even consulted during the entire process.

Problem Recognition and Resolution
After their inquiries, my mother and aunt realized that three main mistakes had occurred which enabled this error to occur:

  • Poor Communication: My grandmother’s current mental state prevents her from making her own care decisions; neither my mother nor aunt were informed by the facility that my grandmother was being removed from her Fentanyl prescription.
  • Mis-applied Medication: The facility caregivers were not applying the Fentanyl patches per the clear instructions in the RASP to my grandmother’s upper back between her shoulders. Instead, they were applied to her upper arm. As a result, my grandmother would simply remove it. If the medication had been applied according to the instructions, my grandmother would not have been physically able to remove it.
  • Faulty Medication List: The medication list that went in January to her chronic family physician during my grandmother’s appointment was not correct due to a dosing error in the facility’s Catalyst medication administration system regarding the current list of medications.

After realizing what had happened and not receiving any real cooperation from the facility’s Executive Director, my mother and aunt went to the corporate level. The Nursing Director who was in charge of quality for the organization reviewed all of the relevant information including my grandmother’s RASP along with information my mother and aunt supplied.

The Nursing Director agreed that the three aforementioned mistakes had occurred. Additionally, she found that the medications list that has been sent to the chronic pain physician in July 2014 and September 2014 during my grandmother’s visits did not have Fentanyl listed as one of her current medications on the list that facility sent over. Despite this mistake both times the chronic pain physician’s office signed off on the medication list as being correct and updated.

As a part of the resolution to this issue going forward the Nursing Director of Quality was to implement three basic changes:

  • Revise RASP Document: Explicit information was added to the RASP to ensure that before any medication change was made, the patient’s family/legal guardian was to be contacted and acknowledgment of this change by the family/legal guardian was to be documented.
  • Medication List: Made several minor changes to the active medications list in the Catalyst system.
  • Documenting Transitions Process and Medications List: Several procedural changes to the process including who signs off on various forms and how they are checked when the patient arrives back to the facility to ensure information in the patient’s RASP and other systems as necessary are correct.

Still a Long Way to Go
One of things that I have run into during my research is the concept of a longitudinal care plan. It is somewhat similar to the notion of a longitudinal patient record except that it has some unique data elements and information relevant to a patient’s care plan.

Even with the changes the Nursing Director of Quality made, the RASP document at the senior living facility is still basically a siloed electronic document that in many ways is still disconnected from any care process outside of the facility. Even some of the care processes within the facility are not electronically linked to the RASP document.

There is no way for family members or providers to electronically access the RASP and check on its content except for a phone call to the senior living facility. Any transition event where my grandmother goes to one of her physician’s visits, either a paper copy of the RASP document has to be sent along or a fax sent to their office. This happens even when she visits here family physician or chronic pain physician despite both of these physicians being in offices that use ambulatory EMR solutions. Any time my grandmother has a visit with her physician, the physician or a nurse in the office has to look up the list of her medications in her patient record on their ambulatory EMR, check it against the information on the paper copy of the RASP document, and sign off to verify it is correct.

Lastly, if anything has to be checked or updated to the RASP document, it is still almost an entirely, manually-driven process that is heavily dependent upon the people involved at the facility to correctly follow well-designed procedures. I would like to think that this incident helped the facility to realize some of their shortcomings regarding transition events and to better maintain accurate medication lists for their patients. But it also demonstrated just how far off we are from having a longitudinal care plan in place between care settings that addresses even modest issues such as accurate medication lists.

2 responses to “Longitudinal Care Plans: Still Siloed”

  1. Dave Carty says:

    Matt, you have done an excellent job in identifying the need for a robust coordination of care policy and process in healthcare. As you so succinctly stated, poor communication, and lack of transitional medication reconciliation was the culprit in the insufficiency of care for your grandmother. What is your opinion of adding an automation component to the healthcare process? For instance, what if we could connect physicians, pharmacies, caregivers and family members to a virtual Circle of Care. Hence, when medications were prescribed, modified or discontinued all members would be immediately notified. This would in a sense create a layer of accountability and proactivity in the delivery of care. More importantly, family members who are most invested in the care of their loved one could take a more active role in the process.

    • Matt Guldin says:

      Thanks Dave. Medication reconciliation was a large part of the problem. Even today with my grandmother having moved back in with my aunt and uncle full-time remains a real challenge. The pharmacy where my grandmothers gets her medications filled does send out automated reminder notices via IVR/text message to my aunt but it doesn’t notify anyone else. This is a huge problem since several other people are involved in her care including 2 private caregivers who come to my aunt’s home almost daily, my mother, and my sister who is a pharmacist aren’t notified. There is also the issue of a few other medications that get filled via mail order separately. With the exception of a list my aunt keeps in a paper binder, I highly doubt that another complete and current medications list is available including even at my grandmother’s PCP or various specialists. The primary way my aunt ensures that there are no harmful contradictions from any of my grandmother’s prescriptions is by talking to my sister first.

      Giving family members and caregivers (non-clinicians) access to a complete list of medications would be immensely helpful. A reconciled meds list is a key point in care plan development today; however, the issue remains providing electronic access to the care plan for family members and caregivers. Based upon our research, even this basic level of functionality is still widely lacking in the market place. If it does exist, it is usually presented via a link embedded in a patient portal or as a static document (.pdf, .doc) that can be clicked upon.

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