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Discharge Planning and Teaching

Sexson, Kathryn PhD, RN, APRN, FNP-BC; Lindauer, Allison PhD, RN, FNP; Harvath, Theresa A. PhD, RN, FAAN

AJN, American Journal of Nursing: May 2017 - Volume 117 - Issue 5 - p 58–60
doi: 10.1097/01.NAJ.0000516274.66604.09
Supporting Family Caregivers: No Longer Home Alone
Videos

This article is the fifth in a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't being given the information they need to manage the complex care regimens of their family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's medications. Each article explains the principles nurses should consider and reinforce with caregivers and is accompanied by a video for the caregiver to watch. The fifth video can be accessed at http://links.lww.com/AJN/A79.

This fifth installment in a series published in collaboration with the AARP Public Policy Institute provides evidence-based recommendations to facilitate caregiver discharge teaching, with the goal of reducing the risk of harm to elders and the stress faced by their caregivers. Includes a video for caregivers.

Kathryn Sexson is a family NP at Denali Family Healthcare and an assistant professor in the School of Nursing, University of Alaska, Anchorage. Allison Lindauer is an assistant professor at Oregon Health and Science University, Portland. Theresa A. Harvath is the associate dean for academics at the Betty Irene Moore School of Nursing, University of California, Davis, in Sacramento. The authors would like to acknowledge Susan C. Reinhard and Heather M. Young, leaders of the No Longer Home Alone video project, and the contributions of Carol Levine, who conducted focus groups with family caregivers regarding the challenges of medication management. Contact author: Kathryn Sexson, kesrs@aol.com. The authors have disclosed no potential conflicts of interest, financial or otherwise.

Managing medications after hospital discharge can be a daunting task for the estimated 34 million adults caring for family members older than age 50.1 What seems relatively simple to nursing professionals can be overwhelming to family caregivers coordinating and administering medications at home. This is particularly true when multiple medications are required, or when the caregiver must manage complex dosing regimens or administration challenges, such as providing medications to someone with swallowing difficulties.

Family caregivers and patients frequently report that they are uncertain about the goal of using a given medication and fear the occurrence of adverse effects.2, 3 This can lead to drug-related problems stemming from errors in administration or a person's inability to adhere to a medication regimen, ultimately contributing to poor outcomes. As many as 46% of older adults experience drug-related problems after leaving the hospital,4 and researchers have estimated that more than 19% of Medicare patients are readmitted to the hospital within 30 days, at an annual cost of $17.4 billion.5

Nurses have an important opportunity to reduce drug-related problems and readmission through discharge planning and teaching. In this article, we provide evidence-based recommendations to facilitate caregiver discharge teaching, with the goal of reducing the risk of harm to elders and the amount of stress experienced by their caregivers.

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BACKGROUND AND EVIDENCE

Hospital admissions often result in changes in the patient's treatment regimen, with hospitalists frequently adding new medications and discontinuing others.6, 7 After returning home, patients and caregivers may be confused about whether to resume home medications, continue hospital medications, or make adjustments based on the patient's response.8

Medication nonadherence is a complex problem in older patients. Pasina and colleagues followed up with patients 15 to 30 days after hospital discharge and again three months after discharge to learn about their treatment regimens and medication adherence.9 By the third month, 69.6% of the study population was not adhering to their regimens, and only 25.3% understood the purpose of their medications. The researchers found that those taking the highest number of medications were the least adherent to the treatment regimen.9

Witticke and colleagues followed 500 patients after discharge and reported on factors that commonly impair adherence, such as taking one or more medications daily that require multiple doses, tablet splitting, and taking three or more medications that have different dosing intervals.10 Almost 40% of the patients in this study required 12 or more administrations of medication daily, significantly adding to the possibility of errors.10

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GUIDELINES FOR DISCHARGE TEACHING FOR FAMILY CAREGIVERS MANAGING MEDICATIONS

In developing recommendations for nursing professionals who work with family caregivers in the context of medication management after hospital discharge, we focused on the principles of adult learning theory: (1) adults bring a variety of experiences, skills, and knowledge to any new situation, which influences how they acquire new knowledge and skills; (2) adults are goal and relevancy oriented; (3) adults are practical; and (4) adults like to be respected.11

In addition, we drew on the principles of the “just culture” movement in health care, which is supported by the American Nurses Association.12 (For a description of the just culture concept, see the first article in this series, “Managing Complex Medication Regimens,” November 2016.)

We identified the following important components of a teaching plan:

* Identify who will be the person assisting with medication management at home. This may not be the person who has been at the bedside.

* Coordinate a time for teaching and return demonstration prior to discharge.

* Identify the goals of care with the family caregiver and patient.

* Provide a verbal and written explanation of why each medication is prescribed, how it works, and how long it needs to be taken.

* Describe how the patient and family caregiver will know if the medication is effective and ensure they also have this information in writing.

* Articulate, both verbally and in writing, potential interactions with other medications. These may include prescription and nonprescription medications as well as herbal or homeopathic preparations.

* Discuss and write down special considerations, such as whether the medication needs to be taken with or without food, by itself (for example, thyroid supplementation), or with other medications (for example, iron and vitamin C).

* Discuss and provide written instructions regarding whether the medication can be chewed, crushed, or dissolved.

* Identify special considerations, such as swallowing concerns, in conversation and in writing. Determine whether a swallowing study has been completed or is needed.

* Describe, both verbally and in writing, the common adverse effects of a medication and when and whom to call should they occur.

* Write instructions clearly. If handwritten, use print rather than cursive writing. If using a computer, choose a sans serif, larger-size font. Ensure these instructions are appropriate for the patient and family caregiver's literacy level.

* Identify whether the family caregiver has access to transportation to the pharmacy. In addition, ask if the caregiver's work schedule allows her or him to pick up medications at the pharmacy during regular business hours.

* Ascertain whether special pharmacy services are needed, such as home delivery, online refills, or medication review and counseling.

* Inquire if the family caregiver has concerns about being able to manage the medication regimen, or if she or he anticipates any potential problems.

* In conversation with the family caregiver, brainstorm and troubleshoot how to avoid potential medication problems, writing down suggestions. Make sure the family caregiver knows who to call (such as the provider, pharmacist, or telephone triage nurse) if the treatment regimen needs to be adjusted or if a mistake occurs, such as a missed dose.

* Stress the importance of coordinating with the patient's provider before making any changes to the medication regimen.

* Help the family caregiver to identify potential resources, such as the Food and Drug Administration's Web site (www.fda.gov) and medication instruction materials. The latter may include medication guides provided at the time of discharge, medication package inserts, and patient information provided by the pharmacist.

* Confirm that the family caregiver understands your instructions by asking her or him to repeat information you've provided, for example, about medication doses and administration times.

Remember that the key to successful teaching is to keep it as simple as possible. Also, ensure that all relevant information is in writing, so the family caregiver may refer to it as needed.

It's important to assure the family caregiver that no question is trivial, to acknowledge that managing complex medication regimens isn't easy, and to emphasize that family caregivers should contact the health care provider if an accident or mistake occurs, so any adverse effects can be minimized.

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VIDEO CASE EXAMPLE

Multiple factors besides complexity, purpose, and volume may contribute to adherence, as demonstrated in the accompanying video, which can be viewed at http://links.lww.com/AJN/A79. In it, Mrs. Thompson is preparing for discharge with her son, Jim, by her side. The nurse notes that some of Mrs. Thompson's medications have changed during her stay in the hospital, necessitating a discussion about her medication schedule before she is discharged.

Jim, who is overwhelmed and anxious about these changes, asks several questions. He notes that he is particularly concerned about making mistakes when administering the medications. The nurse acknowledges his anxiety and reassures Jim that they'll review the list of medications fully. She also gives him a form that he can use to track the administration of these medications, explaining that he can give this form to his mother's health care providers during each encounter.

The nurse has noticed during the past few shifts that Mrs. Thompson has had difficulty swallowing her pills but that she is more successful when she eats applesauce or yogurt just prior to taking the medication. Thus, the nurse offers suggestions to help with swallowing, including the recommendation that Jim never crush the medications but instead give his mother applesauce along with the medications, to make swallowing the pills as easy as possible.

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How to Use This Series

* Read the article, so you understand how best to help family caregivers manage medications.

* Encourage the family caregiver to watch the video at http://links.lww.com/AJN/A79.

* Ask the family caregiver if she or he has any questions.

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REFERENCES

1. AARP Public Policy Institute and the National Alliance for Caregiving. Caregiving in the U.S. 2015. Washington, DC; 2015 Jun. http://www.aarp.org/content/dam/aarp/ppi/2015/caregiving-in-the-united-states-2015-report-revised.pdf.
2. Ahmad A, et al Identification of drug-related problems of elderly patients discharged from hospital Patient Prefer Adherence 2014 8 155–65
3. Ellitt GR, et al Drug related problems after discharge from an Australian teaching hospital Pharm World Sci 2010 32 5 622–30
4. Garcia-Caballos M, et al Drug-related problems in older people after hospital discharge and interventions to reduce them Age Ageing 2010 39 4 430–8
5. Jencks SF, et al Rehospitalizations among patients in the Medicare fee-for-service program N Engl J Med 2009 360 14 1418–28
6. Harris CM, et al What happens to the medication regimens of older adults during and after an acute hospitalization? J Patient Saf 2013 9 3 150–3
7. Kripalani S, et al Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists J Hosp Med 2007 2 5 314–23
8. Hugtenburg JG, et al Medication review and patient counselling at discharge from the hospital by community pharmacists Pharm World Sci 2009 31 6 630–7
9. Pasina L, et al Medication non-adherence among elderly patients newly discharged and receiving polypharmacy Drugs Aging 2014 31 4 283–9
10. Witticke D, et al Opportunities to reduce medication regimen complexity: a retrospective analysis of patients discharged from a university hospital in Germany Drug Saf 2013 36 1 31–41
11. Knowles MS, et al The adult learner: the definitive classic in adult education and human resource development 2015 8th ed. New York Routledge
12. American Nurses Association. Just culture. Silver Spring, MD; 2010 Jan 28. Position statements; http://nursingworld.org/psjustculture.

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