Medication Management Module - Business Innovation Factory

Medication Management Module - Business Innovation Factory

Business Innovation Factory

Nursing Home of the Future Laboratory

Medication Management Module

Winter 2009


Medication Management Module

The Business Innovation Factory’s Nursing Home of the Future Lab (NHoF)

Medication Management Module launched with an eight week focus on the

day-to-day experience of elders managing medication.

The NHoF team conducted research with elders living in assistive living and

skilled nursing home environments, and with their caregivers. Engagement

included focus groups, staff interviews, elder interviews, direct observation,

and a design workshop with elders in assistive living. Secondary research

included an evaluation of regulations, common practices, trends, and

commentary surrounding the needs of elders and caregivers regarding

medication management.

The lab explored elder attitudes and behaviors associated with receiving, storing,

taking, and tracking their medications. The objective of this work was to identify

opportunities where intervention and re-design can improve medication

management and deliver a better experience to all elders.

• System Barriers to Enabling Greater Elder Independence

• Driving Forces Behind Medication Management in Assisted Living

• A Spectrum of Assistance

• Managing Frequent Changes of Treatment & Prescription

• Cassette Refill Service in Assistive Living

Emerging Themes &

Opportunities in

Medication Management

Our research revealed a subset of experiential drivers that

have significant effect on an elder’s quality of care and quality

of life. The “themes” reveal the challenges of medication

management and illuminate areas of the experience ripe for

re-design and innovation.

• Ergonomics of Packaging & Re-Packaging

• Medicine De-Identification

• Privacy

• “The Temp” or Substitute Caregiver

• Culture Change Impact on Medicine Management

• Side Effects

• Trust

• Lack of Standardization

• Discarded Medications

• Increase in Medication after Entering Long Term Care System

• Anticipated Future Developments

System Barriers to Enabling Greater Elder Independence

• Current system relies on medical language

Medication information formatting, such as font size, is difficult for

older users

• Current products, like pill storage cassettes, separate medications

from identifying information included on packaging

• Packaging and delivery systems are ergonomically difficult

The Challenge

The cognitive and physical demands of medication management

systems leave many elders dependant on assistance. The current

system is designed around a medical model, not around the

needs, behaviors, and capabilities of elders themselves.

The Opportunity

A comprehensive understanding and appreciation of the elder

experience has been all but absent from the evolution of elder

medication management systems in the U.S. Simply putting the

elder experience directly at the center of the system will open

up opportunities to design products, services, and systems that

better meet elder needs, wants, and demands.

“When you get the medicine from the pharmacy, with the pill comes

a booklet telling you what color the pill is, what to do if you forget to

take it... They give you all that information, but for the people who

take many medications…it’s extremely complex. And I think it’s really

dangerous to not know what you’re taking. And we don’t always

see all [of the literature] that we should, know all that we should; it’s


- Susan, elder age 78, determined to manage her own medication but

struggles to do so

“Marianne who is 82 years old and fairly independent, does not attempt

to manage her medication herself because it is ‘too confusing’.”

- NHoF design team

p. 1

Driving Forces Behind Medicine Management in Assisted Living

Forces driving med management include:

• State regulations

• Best practice care models

• Principals of Culture Change (in limited facilities)

• Staff experience

• Elder demands and desires

• “Do it yourself” approach of individual elders

• Level of elder assistance desired or required

The Challenge

The challenge is identifying which factors have bearing in

an individual situation, in what priority do they need to

be addressed, and finally, how will these factors effect an

elder’s independence.

The Opportunity

New medication management solutions that enable

elders to tack, store, take and understand their

medication will enable more elders to live independently

longer within assistive living facilities; these types of

solutions would also have wide reaching impact on aging

in place and other independent living options.

“Rightfully, state regulators had safety in mind when requiring

all medication, including over the counter, be locked, or in some

cases double locked, within a resident’s apartment, regardless of

an elder’s level of independence. We see lots of opportunities for

design of this storage system - lots of possibilities!”

- NHoF design team

p. 2

A Spectrum of Assistance

The level of assistance provided to an elder may be determined

by several factors, including:

• Individual elder preference

• Elder’s ability and capability

• Habit or routine

• Medical requirement

• Elder’s family, long term care staff, doctor, pharmacy

• Insurance constraints

• Elder psychology - “I choose to have someone else help so that I

don’t have to think about it.”

The Challenge

Some elders choose to and are capable of managing

their medications independently, but many require some

medication management assistance that Long Term Care


The Opportunity

Replace “one size fits all” and “do it yourself” approach to

medication management with more modular and flexible

support services and technologies that can be tailored to

individual elder needs, wants, and capabilities.

“I was a nurse so I don’t find this too complicated to manage

myself, I have my system.”

- Maria, retired nurse and independent elder age 87

“This [discussion] makes me think, I really don’t even know what

I’m taking anymore, I used to, now I just take what I’m handed,

Id like to know more but its hard to keep up.”

- Belinda, elder 94, receives full med management assistance

p. 3

Managing Frequent Changes of Treatment & Prescription

• Treatments and medications change due to shifts in overall

health or a transition from one facility or level of care to another

• Adds complexity to elder’s self-care

• Adds complexity to caregiver’s coordination

• Increased opportunity for error

• System relies heavily on paper records

The Challenge

Changing conditions require careful coordination and

oversight of a resident’s entire medication plan. Records

must always be updated to reflect most current care plan.

The Opportunity

Proper system design and integration of advanced

technologies, such as electronic record keeping and

comprehensive communication systems, would benefit

elders, caregivers and elder care facilities.


Polypharmacy: Undesirable state caused by use of

duplicative medications, drug interactions, and disregard for

principles of pharmacokinetics, and pharmacodynamics.

Polymedicine: Multiple medications prescribed

appropriately for older adults to treat one or more disorders

(or diseases) in addition to a primary disease or disorder.

p. 4

Cassette Refill Service in Assisted Living

Many assistive living facilities offer a cassette refill service:

• System for managing weekly and daily medication

• Scope of service varies based on need and/or preference

• Service includes tracking changes, pharmacy orders and filling

the weekly cassette

• Elders report the task can be daunting due to complexity and

required dexterity

• Often a fee-for-service option

The Challenge

Some facilities provide services (at an additional fee) for refilling

a resident’s cassette weekly. Elders choose this service

or, in some cases, are required by their doctor to utilize this


The Opportunity

Rethinking the cassette, from design to utilization, would

create opportunities for new products aimed to improve

the medication management experience and which are

attractive to the next generation of elders.

“We do this [cassette refill] for most of the of assisted living

residents, it requires so much manual dexterity and focus. If

someone walks in while I’m doing it I have to be really careful not

to lose track. It can be too much for many residents, and its so

important to their health.“

- Nursing staff on refills and medicine management assistance

p. 5

Ergonomics of Packaging & Re -Packaging

• Requires fine dexterity and visual skills, senses which

increasingly fail with age

• Rigorous organization needed for accuracy

• Lack of ability to customize the system

The Challenge

Products currently on the market for medication storage and

organization do not take in to account varying levels of ability

or personal preference. Pill bottles, cassettes, and lock boxes are

difficult to maintain and maneuver for residents and staff alike.

As well as being challenging, repackaging medication creates

room for error, can add expense through contaminated meds or

have medical implications.

The Opportunity

Rethink medication storage and delivery devices to consider

individual elder capabilities and preferences. Opportunities

abound at system integration level.

“I put my medication into a large weekly cassette and then a

smaller daily one each day and I keep the emergency medication

for my heart in two shot glasses so the medical staff could get to

them easily; its my system.“

- Maria, elder age 87

p. 6

Medicine De -Identification

• Medicine management systems and devices distance elders from

medication information

• Pills are removed from bottle and transferred to cassettes for intake

• Most pills have a generic look with no identifying information

• Over time elders are unable to identify medication independently

• Experience depersonalizes medication, which adds to elder

disengagement from care

The Challenge

Once it is out of the bottle, inability to identify medication

is a common concern for elders, complicates self-care and

often triggers staff assistance. Medication that has been

transferred to cassettes for safe and effective intake is separated

from identifying information. While the cassette assists with

scheduled intake, deidentification increases chance of mistakes

and creates discomforting confusion for the elder.

The Opportunity

Changes to medication packaging, storage devices, and intake

services will enable elders to take a more direct role in self care

longer and to be fully informed about their medication regime.

“Speaking of the cassettes, Bernadett the nurse comes around

every Tuesday and fills our weekly cassette. Of course by the time

I take it, all I know is what the pills look like, I don’t know what

bottles or containers they came from. If you ask me what I’m

taking at a meal I don’t even really know…”

- Belinda, elder age 92

“ Which is my hear t med”

p. 7


• Privacy is an important factor expressed by many elders

• Relationship between caregiver and elder is key

• Trust and respect are central to maintaining dignity

• Current system struggles to balance elder preferences with protocol

The Challenge

There is often a conflict between practices developed for

effectiveness in institutional operations and an elder’s desire

for privacy.

The Opportunity

Although developing customizable medicine management

systems that address individual concerns and preferences

seems daunting, a move in this direction is likely to pay a

return on investment through improvement in compliance,

reduction in error, less waste, and an improved elder


“We cant keep things in the bathroom

because we share bathroom spaces. My

meds are in my room, I wouldn’t want

anyone else to touch them or see them.”

- Maria, elder age 87

p. 8

“The Temp” or Substitute Caregiver

• Elder routine may be ‘thrown off’

• Unfamiliar caregiver causes elders not to trust ‘the med

in front of them’

• Consistent systems, preferences, expectations and

routines are key

The Challenge

In the event that a Med Tech or CNA is absent, or there is an

unexpected shift in staff schedules, a substitute may be brought

in. The substitute does not know the individual needs and

preferences of the residents, which disrupts established routines.

The Opportunity

Staffing programs aimed to minimize disruptions could be

better supported by communication tools that make elders

needs and preferences more readily accessible to a substitute

staff. Thinking long term, designed systems that support elder

self care will minimize disruptions and trust concerns associated

with a substitute caregiver.

“I don’t want anything to do with my lock box and medication,

Bernadett [RN] handles that, I trust her, she knows what to do. I

don’t want anyone else doing it.“

- Harriet, elder aged 92

“And that’s when you’ll see the cart [is] not organized. [Usually]

its set up so Carleen knows exactly where everything is, but after

somebody from the pool comes in…and with that said residents

will get really irritated and say ‘I’m not taking that’ because usually

its crushed and its not crushed, its usually with cranberry juice

and they’re used to cranberry juice… Usually I only administer the

narcotics [as the charge nurse] but that’s when Ill step in, because

the [residents] are out of their comfort zone, they’re leery.”

- Sue, nurse

p. 9

Culture Change (Resident Centered Care) Impact on Medicine Management

Culture Change is changing medicine management by virtue of:

• Firm commitment to value elder desires and to preserve


• Development of strategies to enable elders to make independent


• Systems aiming to encourage choice and recreate community

• Acknowledgement that regulations may conflict with elder’s


• Emphasis on staff training and retraining around Culture

Change ideals

The Challenge

Culture Change is a progressive care model which is elder

centric, rather than institution-centric in its approach

to long term care. Culture Change affects how and

when medications are delivered; in some cases who is

in control of meds; where they are stored and how they

are administered within long term care facilities. Culture

Change is not yet widely adapted across elder care

facilities but gaining in popularity.

The Opportunity

The Culture Change movement offers caregivers new

models and strong support for creating systems and

environments that foster elder-centric care.

“The nurses said, ‘we think what we’re doing works

perfectly fine right now.’ I said, ‘It works perfectly fine

for the medical model, but we’re moving towards a

social model and we need to communicate other things

[too]. Some of those other things are more important

than the medical information. What caused Mrs. Smith

to have a good day is just as important as knowing her

blood sugar.’”

- Deborah, nurse discussing retraining staff on the

social model of long term care

p. 10

Side Effects

• Many elders feel that their concerns about side effects are not

adequately addressed

• Side effects are a source of worry and confusion for many elders

• Many elders expressed a desire for more communication about

medication and its effects

• Side effects can be difficult to spot and misinterpreted as unavoidable

consequence of old age

The Challenge

Many prescriptions have severe side effects that are just as

present for elders as the illness itself. They can be the source of

confusion and worry in many cases. One-time oral advice from

a doctor and standard documents are not sufficient for elder

patients to truly understand, manage, and adapt to drug effects.

The Opportunity

Elders need new ways to understand and communicate about

medication to keep them informed and protected. Existing

technologies, combined with appropriately designed systems,

could assist elders in understanding risk, spotting and reporting

problems, tracking their history, and enable more informed


“Side effects are almost worse than taking the medication... and I

love when they say ‘only,’ that amuses me, when they put that in,

side effects are ‘only this’ and ‘only that’.”

- Regina, elder 85

p. 11


• Relationships must be built long-term

• Communication is key, but can be difficult for both elder or


• Elders often feel no one is more invested in meds than they are

• Fear and lack of trust can inhibit compliance, which can have

direct medical impacts

• Current system does little to acknowledge the emotional

components of medication management

The Challenge

Trust is important in the relationship between an elder

and the caregivers who are charged with managing their

medication. If trust is broken at any point, the elder is less

likely to adhere to prescribed medical therapies.

The Opportunity

Rethinking the medication management system with

an eye toward both the physical and psychological

experience of the elder, and the dynamics of the elder/

caregiver relationship, will reveal new opportunities for

improving medication compliance and quality of life.

“Do we trust whomever prescribed

Do we trust the prescription The

relationship Do we trust the doctor”

- Beatrice, elder age 89

p. 12

Lack of Standardization

• Generic and name brand drugs look different; substitutions

are common

• Elders rely on look of pills to know what they are taking

• Elders may not be notified of brand switch

• Changes in packaging are often not explained, resulting in


• Included documentation may meet legal needs, but is often

insufficient and inaccessible for many elders

The Challenge

Currently no single standard exists for the packaging of

medicine. Pills come in a variety of sizes, shapes and packaging,

often even when the medication and dosage are identical and

only the manufacturer differs. Many people have difficultly

identifying a medication by looking at the “pill.”

The Opportunity

Significant opportunities to improve elder experience exist in

the redesign of medication packaging and delivery systems that

consider elder capabilities, preferences and needs. Enabling

more elders to self manage medication can reduce staffing costs

and, in some cases, preserve independence longer.

“We heard multiple stories of elders unable to recognize

their ‘new‘ or ‘changed’ medication even though it was

treating the same condition.”

- NHoF design team

p. 13

Discarded Medications

Prescription meds must be discarded when:

• They are dropped

• A prescription changes

• In the case of pharmacy error

• Staff error

• Prescription error

• A elder passes away

• A elder’s condition Improves

• A elder refuses medication after medication is prepared

The Challenge

Elders and Staff feel strongly about the amount of medication

that must be discarded. It bothers them both from a cost and a

waste perspective. Changes and mistakes occur regularly, and

regulations demand that the medication involved be destroyed.

The Opportunity

Managing the costs of medication is a significant issue for many

elders, their caregivers, and elder care facilities. Opportunities

exist to improve how medication is tracked, stored and delivered

to reduce the unnecessary disposal of valuable medication.

“And then we throw them away, that’s what [your research]

should work on, we throw meds away all the time... We

cannot legally take medicine from Mrs. Smith’s blister pack

and give it to Mrs. Jones, because we would be acting as

pharmacists. The week before last we threw away a box this

tall [about three feet tall]. Its the same every three months. It

gets incinerated. We end up throwing away perfectly good

medications, that are in a blister pack; we’re not talking

about contaminated meds in a bottle.“

- Beatrice, Nurse

p. 14

Increase in Medication after entering Long Term Care System

• Staff and elders report that ‘it is expected’ an elder’s medications

increase when entering long term care

• Many questioned the medical necessity of an almost immediate

uptick in medication

• As medication regime grows more complex, risks of error and side

effects increase

• Trend appreciated anecdotally, but still embedded in system

The Challenge

After moving into long-term assistive care, it appears inevitable

that an elder’s medication regimen is affected. Elders and staff

notice an increase in the quantity of prescribed medication.

The Opportunity

Much can be gained from taking a more comprehensive look at

medication protocol for elders entering long term care. Our work

makes clear that there is a need for systems-level thinking about

medication and the effect increasing medication has on elders.

“When moving into assistive living, a person’s doctor may change;

and with that new doctor-patient relationship sometimes comes

new prescriptions; we see it all the time.“

- Sue, certified nurse assistant

“We have met many residents who took only a few pills when they

lived at home but since moving into long term care have found their

medication increase without clear understanding as to why.”

- NHoF design team

“When I was away I accidentally forgot my medication and so I went

around for a week without them and I actually felt better. That

makes me wonder about my medications.“

- Beatrice, elder age 89

p. 15

Anticipated Future Developments

Staff and elders await the following developments:

• Standardized EMR (Electronic Medical Record)

• Paradigm shift to social model of care

• Growing demand/expanded market with arrival of


• Economic, environmental and social sustainability as

motivation to drive change

• Higher elder expectations with arrival of babyboomers

• More federal regulations for assistive living, which are

currently thin

The Challenge

Medicine Management is critical to the health and wellness of

elders. Elder care will be reconsidered as demand for services

grows exponentially with the arrival of the babyboomers.

Regulations may increase, but there will also be more demand

for a paradigm shift in how elder care is provided.

The Opportunity

Many aspire for more sustainable solutions - more economically

viable, environmentally friendly and socially acceptable

processes. Enabling technology already abounds. Significant

opportunity lies in developing new models that effectively

integrate new technology to deliver a high quality, affordable

care for our nation’s elders.

“We’re working on getting a computer system to

manage data but it has to work with the pharmacy

system and the hospitals. Getting them all to line

up right now, so they can basically talk to each

other, is still hard. But we’re doing the research and

will get there.”

- Bernadette, nurse

p. 16

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