Findings include a description of the settings, quantitative results of the SMMS, and qualitative description of the various roles in the medication management process.
Satisfaction with Medication Management Survey
SMMS Sample. The SMMS assessed satisfaction with medication management and perceptions of the preparation and capabilities of UAP to manage medications. The sample of 82 respondents came from eight facilities in Washington and Oregon. Demographic characteristics are summarized in Table 4 and reflect younger age and greater diversity among UAP, and a high proportion of women among residents, UAP, and nurses.
Demographics of the Sample
Table 5 summarizes satisfaction with medication management and includes item scores and the total score by role. The scale has strong internal consistency, with Cronbach’s alpha = 0.87. The total satisfaction score for the entire sample was 1.81, indicating overall high satisfaction with using UAP to manage medications in AL. UAP were the most satisfied overall, followed by residents. Although PCPs and pharmacists were the least satisfied, mean total scores of health care professionals (RN/LPN, NP-PCP, MD-PCP, and pharmacists) were all in the 2 to 3 range, indicating moderate satisfaction.
Satisfaction with Medication Management by Role and Survey Item
In examining the item scores, UAP perceive themselves as more prepared and more capable than any other group’s perception of their readiness. The pharmacists believed UAP were fairly capable, though not as prepared and they were somewhat willing to promote this practice, but they and the PCPs were dissatisfied at the lack of choice in deciding whether UAP could assist with medications. RNs/LPNs and nurse practitioners (NPs) had similar ranges of mean scores. Both were moderately satisfied with the capability of UAP, slightly less satisfied with their preparedness, but were willing to promote UAP in this practice. For NPs, the highest mean score (least positive) was related to the question about choice in the decision of whether UAP would assist with medications. For RN/LPNs, the two items tied as least positive were about the capability of UAP to assist with medications and whether they had choice in deciding whether this practice occurred.
Group differences in satisfaction were also examined, comparing four groups: residents, UAP, facility professionals (nurses and administrators), and external professionals (PCPs and pharmacists). Overall trends were positive for UAP medication management, with facility professionals and residents similarly positive; however, external professionals were the least positive about UAP managing medications. Total satisfaction was statistically significantly different among these groups as determined by one-way ANOVA, F(3, 77) = 10.21, p < 0.000. Because the scores met the assumption of homogeneity of variance, Tukey’s honestly significant difference post-hoc test was used to examine the group differences, substantiating that the external professionals had a more negative perspective on UAP managing medications than any of the other three groups (p < 0.05).
Roles in Medication Management
Qualitative Sample. The qualitative data provide a description of the roles and perceptions of participants in the medication administration process. The sample included 112 participants in 15 facilities in Washington, Oregon, Illinois, and New Jersey.
All participants commented on their own roles and expectations related to other members of the team. The themes (Table 6) elaborated below for each role reflect a synthesis of these perspectives. Except where specifically noted, there was solid agreement among perspectives on the themes that emerged. As might be expected, those most closely involved in medication administration (UAP and nurses) provided richer descriptions of the roles. There was also solid agreement across states on role themes except for the state regulatory variations described in roles of UAP, RNs, and pharmacists.
Roles in Medication Management in Assisted Living (AL)
AL Resident Role. The first resident role theme was deciding to get medication service. The residents predominantly viewed the assistance in medication management provided by the AL facility as a benefit, making managing their medications easier and safer because they struggled with remembering to take their medications on their own. Some reported being reluctant about starting medication service, either because of the added cost, or because of fear of loss of autonomy, but had become comfortable with the ease and safety it ultimately provided.
The second resident role theme was communication link between external providers and AL staff after health care visits outside the AL facility. After a visit to the PCP, emergency department, or hospital, residents reported that they or a family member were responsible for giving new or updated information about medications to the nurse or UAP on duty. Most residents were appreciative of medication service and reported positive communication with UAP and nurses about their medications.
The third resident role theme was asking questions and reporting concerns. Most residents identified the AL nurse or the PCP as the individual they would go to with questions about their medications. Residents report problems or concerns about the administration of their medications to either UAP or the AL nurse. Although a few residents expressed concerns about the qualifications of UAP helping them with medications (e.g., “They just hire them off the street”), most seemed unaware of the training or preparation of UAP and viewed them as competent because of positive personal relationships and helpful interactions with them.
UAP Role. The first and most discussed theme in the UAP role was passing, verifying, and documenting the delivery of medications to residents. In Illinois, regulation limited “passing medications” to handing pre-packaged medications to residents. Verification that residents took their medications and documentation of this was common to all four states. The “medication pass” was a central focus of the UAP role in medication management in New Jersey, Oregon, and Washington. Medication administration passes were described by UAP as physically and mentally demanding times with a large volume of medications needing to be administered correctly in relatively limited periods of time, while maintaining concentration and accuracy. For example, we observed one UAP who administered 375 medications to 49 residents in a 2-hour time frame. In addition to the intense time demands of such a medication pass, UAP report being challenged by the physical demands of assisting frail or confused residents: “It’s hard sometimes because they’re confused and declining.” Some UAP reported that concurrent job tasks (e.g., assisting a resident with a personal care need or responding to an emergency) create additional demands on them while administering medications. In addition, UAP were often responsible for additional tasks needed to facilitate medication administration: calling in new orders to the right pharmacy; ordering medications; stocking medication carts or room-based medication storage boxes; pulling old medications when told to do so by the RN; and packaging medications for residents going on family/community visits outside of the facility.
The second theme in the role of UAP was relational demands. The work of UAP in medication management was described as relationally demanding and required strong support from the RN. UAP report communicating with residents about new medications or reminding residents about the purpose of the medications they are taking. If a resident initially refuses a medication, UAP described attempting to explain why the medication is important and encouraging the resident to take it. UAP described the challenge of convincing a confused resident to take a medication: “We make three attempts to convince if initially refused.” UAP report the need to communicate frequently with professionals on the team (i.e., RN, PCP, and pharmacist). They report medication errors or unusual incidents to the RN. They may also need to communicate via phone or fax with PCPs regarding unusual incidents, request order clarifications, or report resident changes. They may communicate with multiple pharmacies about orders or medication supply issues.
The third theme in the UAP role is relationship with supervising nurse. In the area of supervision and training, regardless of the parameters set by different regulatory structures across the states, an important relationship is the one between UAP and facility nurse. UAP described routine reporting about resident changes such as side effects for routine medications, side effects for higher risk medications such as warfarin (Coumadin®) (bruising or bleeding), exceptions such as resident refusal of medications or “leftover” medications, and general changes in resident behavior or conditions (“Just noticing if something is different.”). UAP felt supported by having the nurse available for consultation via phone on evenings, nights, and weekends. UAP described facility-specific systems for routine written documentation and communication of issues to the nurse. Although formal preparation for the UAP role was limited and varied by state, UAP described the nurse as the person who provided facility- and resident-specific training beyond the state mandates and individual instruction for performing tasks under applicable nurse delegation protocols. UAP consulted with the nurse in problem-solving team or resident issues.
A fourth UAP role theme was selected tasks to promote quality. UAP described a sense of accountability and responsibility that went along with their work. During medication administration, UAP reported being cognizant of the need for accuracy and the “rights” of medication administration—right person, right drug, right dose, right form, right route, right time, the right to privacy, and the right of the resident to refuse medication. They reported worrying about residents after they left work and calling the facility to follow up regarding medication-related details they forgot to report at the end of their shift. Facility nurses reported that they rely on UAP to report changes in the resident but also worry about their ability to understand the complete picture of what is occurring with residents and the risks or urgency associated with certain medications. Some UAP reported a role in quality monitoring. Monitoring tasks reported included monthly checking of new medication administration records (MARs) to ensure that items on newly printed MARs matched the orders; checking incoming medications to ensure they matched the MARs; sending out quarterly MARs to PCPs for their review; and processing changes on MARs when orders come back from PCPs.
The fifth theme in the UAP role was team leadership. UAP performing the medication administration/assistance functions were often the most experienced or strongest caregivers in the facility. They described a role of team leader, especially during hours when the nurse or other managers are not present in the facility. They might cover for another medication aide so that he or she can concentrate on monthly MARs review; come in early or stay late to finish important tasks; or assume other roles as needed (e.g., caregiver, wait staff, dishwasher, receptionist, supervisor) to facilitate the work of the team. In summary, the UAP role is the frontline of AL medication management. As the staff members who spend the most time with residents, they are perceived by all participants as key to safe and effective medication services.
RN Role. Overall, the RN role was described from all perspectives as essential to safe medication management in AL. LPNs and licensed vocational nurses (LVNs) were found to perform selected functions comparable to the RN role at two facilities, and their narratives are included with the RNs’ narratives.
The first RN role theme was clinical assessment and oversight of resident health and care. Tasks related to this function include resident assessment for self-medication or need for medication assistance; assessment of residents relative to medication effectiveness and potential side effects; monitoring residents with variable dose and higher-risk medications (e.g., psychotropic drugs, anticoagulant agents, insulin, analgesic agents); regular clinical assessment of resident health to discern changes necessitating further evaluation by the PCP and possible medication changes; collaborating with other health professionals regarding resident care needs and health changes; review/update of changes ordered following a PCP visit or transfer from another setting; and overall coordination of admission, discharge, and ongoing service plans. RNs may also provide selected direct medication administration tasks, depending on the state regulations and facility policies. The community retail pharmacy (Young et al., 2008) added a complexity not present in other institutional settings. Depending on residents’ pharmacy coverage, the facility may be receiving medications from several different pharmacy providers or systems so that coordination by the RN to accommodate multiple, disparate pharmacy providers may be needed.
A second RN role theme was supervision and training. RNs described the need to understand both state scope of practice regulations for RN, LPN, and UAP roles as well as state regulations regarding delegation of medications and clinical procedures to UAP in AL. The RN has to negotiate delegation and medication administration functions when LPNs are part of the AL staffing model and when home health care or hospice agencies are involved in a resident’s care. Supervision involved ensuring that UAP and LPNs are not going beyond the state-defined scope of their practice and being available (in-person or via telephone) for questions, changes, or resident problems. UAP reported highly valuing having an RN available for questions and consultation. RNs reported being involved in training UAP in a variety of ways: teaching facility-specific medication administration policies and procedures; teaching medication administration fundamental skills; facilitating UAP access to standardized, state-based training; testing UAP medication knowledge; direct observation of UAP medication passes; providing resident-specific instruction regarding new or higher-risk medications; and ongoing training for UAP about medication administration and side effects.
A third RN role theme was error processing and management. RNs reported being responsible for taking reports regarding medication errors or suspected errors, investigating the incident, and assessing the resident involved. Based on the resident assessment and situation investigation, the RN needed to follow up with residents, families, PCPs, and pharmacists as necessary. RNs discussed providing follow-up counseling and retraining as necessary with the staff involved. Finally, the RN assured that required documentation of the event was reported to appropriate parties/regulators.
A fourth RN role theme was quality monitoring. Nurses reported monitoring occurring at the individual, group, and facility level. At the individual level, they described providing oversight and monitoring of individual resident medication profiles and looking for problems such as duplicates, contraindications, timing issues, and undocumented medication changes. They also assessed the competence of each individual UAP through skill testing, direct observation of medication administration, feedback from residents and other staff, and daily supervision and communication. At the group level, the RN promoted quality through regular monitoring of UAP assignments and staffing, medication order transcription and processing, MARs, audits of the medication room/carts for missing or extra medications and proper storage of medications, the controlled medications log, and all aspects of the environment for cleanliness and proper use of infection control procedures related to medication administration. At the facility level, RNs described tasks reflecting system-level quality promotion and monitoring such as developing and assuring that needed systems are in place and evaluating existing systems and troubleshooting with relevant parties such as pharmacists, administrators, PCPs, staff, and residents/families. RNs were generally tasked with dealing with complaints about clinical care and following up on medication issues that were identified in regulatory facility surveys.
PCP Role. The first PCP role theme in medication management was overall assessment of resident health status. PCPs included nurse practitioners (NPs) and physicians. Some saw residents off-site in private practices in the community. Others made regular visits and followed residents on-site as the facility NP or medical director. NPs often saw frail older adults at several different types of community-based residences, including AL facilities. The second PCP role theme was medication profile determination and review. Although some community PCPs described superb periodic medication reviews, our observation was that comprehensive medication review was done more consistently for residents in facilities with a PCP (MD or NP) who was regularly on-site and in New Jersey, where regular pharmacy review was a regulatory requirement. A frustration noted by PCPs in rural areas was the challenge of managing medication profiles for mental/behavioral health issues when there was a lack of geropsychiatric experts in the community with whom to consult.
The third PCP role theme was communication with AL facility staff. PCPs in the off-site practices reflected less understanding of facility processes and staff preparation than those who regularly visited residents in the AL community. PCPs did not report being involved in training or supervision of UAP and, except for those employed as a facility medical director, did not report involvement in quality monitoring in the facility. “Care management by fax” was reported as an irritant in the role of community PCPs who faced frequent fax communications from the facility regarding medication issues. Some expressed frustration at the communication from UAP and a lack of understanding of the limited scope of practice of UAP in relation to RNs and the context of the AL environment in general. PCPs reported receiving incomplete clinical information related to poorly articulated clinical problems. This frustration with the limited expertise and scope of UAP practice was exacerbated because of frequent faxes from facility UAP, which were time consuming and for which the PCP would not be paid unless the resident was seen for an office visit.
The Pharmacy Role. The first theme in the pharmacy role was communication with PCPs. This role includes clarifying orders with PCPs when necessary and making recommendations to PCPs regarding medications when appropriate. The second pharmacy role theme was dispensing, packaging, and delivering medications to the AL facility. There was frequent communication between facility staff and pharmacies regarding medication changes and questions from the staff (e.g., dosage, interactions).
A third pharmacy role theme was contracted tasks as facility pharmacy. Many facilities had a contractual agreement with a community pharmacy. Under these agreements, the pharmacy assists the AL with tasks such as generating MARs for all residents in the facility, collaborating in developing pharmacy procedures, and assuring that pharmacy regulations are followed (e.g., tracking controlled drugs). Except for New Jersey, where regulations require pharmacist involvement in systematic medication review, there are no regulatory requirements for having quality enhancement programs to review higher-risk medications and medication reduction. New Jersey AL staff were positive about this additional pharmacy involvement, citing additional beneficial services provided as a part of the required quarterly consultation, such as review of facility medication administration processes, medication error review, and training for the medication aides.
Facility Administrator Role. The first administrator role theme was regulatory compliance and oversight of facility policies and procedures for medication management. Administrators described ensuring regulatory compliance of facility policies and procedures and overseeing the response to medication management events/incidents that might put the facility at risk. Administrators often reported delegating clinical oversight of UAP and resident care to RNs, who would ensure that UAP are properly trained and collaborate with the administrator in ensuring that adequate staffing is provided for medication management. Although some administrators with a nursing license may be more directly involved in selection, supervision, and training of UAP involved in medication management, most appropriately delegate this clinical oversight to the facility nurse. Responsibility for managing costs and ensuring financial resources for safe medication systems were consistent role expectations.
A second administrator role theme was managing contractual relationships and costs as well as ensuring financial resources for safe medication systems. This theme involved collaboration with the facility nurse in planning a safe and effective staffing mix and prioritizing resources to ensure medication administration was safe. It also involved managing contractual arrangements with consultant pharmacies and, if applicable, the medical director, who work with the facility on medication management.
The third identified role of administrator was operational leadership to manage risk and negotiate diverse needs. Operational leadership was described as providing structure and leadership for managing risk by balancing needs of residents, facility staff, outside providers, contractors, and regulatory bodies. Descriptions included an active role in problem solving with pharmacy systems and ensuring that residents receive medication services needed and required by regulations.