4-Part Protocol Improves Care, Lowers Costs for Hospitalized Parkinson's Patients

Medication management is the primary focus of a new care protocol for Parkinson's disease patients in the hospital setting.

Caring for hospital patients who have Parkinson's disease poses challenges for hospitals and health systems, but a new protocol drives significant clinical and financial benefits.

Research has shown that hospitalized Parkinson's patients have higher costs of care compared to patients without the disease, including longer lengths of stay and higher medication costs. A New Jersey-based healthcare organization has worked to improve these metrics.

In 2017, Hackensack University Medical Center in Hackensack, New Jersey, formally launched a strict medication adherence protocol for Parkinson's. In June 2018, the protocol was recognized by The Joint Commission as the Disease-Specific Certification in Parkinson's Disease.

Medication adherence is crucial in the care and daily functioning of people with Parkinson's, says Hooman Azmi, MD, director of the Division of Functional and Restorative Neurosurgery at Hackensack University Medical Center.

"Patients with Parkinson's have a significant reliance on their medication. Most patients with Parkinson's develop motor symptoms such as rigidity, stiffness, difficulty moving, and tremors. Rigidity and difficulty moving are particularly debilitating. The patients require their medicine for these symptoms to go away," he says.

In the outpatient setting, patients with Parkinson's work closely with neurologists to develop finely crafted medication regimens, Azmi says.

"When someone has Parkinson's for a long time, the management of symptoms becomes challenging because the effect of medicine is not long-lasting, and it becomes shorter and shorter. They end up requiring more and more doses of medicine. Sometimes, patients take medicine every three hours—or every two hours—around the clock. If patients don't take their medicine or the medicine is delayed, their symptoms can come out. Basically, they can go from being mobile to almost not being able to move," he says.

The strict medication adherence protocol for Parkinson's developed at Hackensack University Medical Center has generated statistically significant reductions in length of stay and hospital readmissions:

• Length of stay for all Parkinson's patients at the hospital decreased from 7.125 days in 2017 to 6.750 days in 2018.
   
• The readmissions rate for Parkinson's patients decreased from 13.9% in 2017 to 12.8% in 2018.

Hackensack University Medical Center's four primary components of the  medication adherence protocol are as follows:

1. Patient identification
 

Most patients with Parkinson's do not go to a hospital for treatment of the disease, so identifying them and their underlying condition can be a challenge, Azmi says.

"They come into the hospital for everything that everybody else comes into the hospital for—they come in for back pain, kidney stones, heart attacks, and all kinds of conditions. The Parkinson's can be missed in the shuffle because caregivers will focus on the main reason why the patient came to the hospital. So, strict adherence to the Parkinson's medication can be completely misplaced and patients don't get their medication on time, which compounds their problems in the hospital," he says.

HMHUMC is using the hospital's electronic medical record to identify Parkinson's patients, Azmi says. "Whenever a doctor or nurse opens a chart of a patient who has Parkinson's, a flag comes up identifying the patient with the disease. Then care plans are included in the electronic record including the timing of medication and contraindicated medicine."

Delays in administering Parkinson's medications as short as 15 minutes can "wreak havoc," he says.

2. Metrics to assess medication management
 

To help ensure strict adherence to medication regimens, the hospital monitors several metrics for Parkinson's patients, Azmi says. "The metrics include patient identification, making sure all of the medicines are in the formulary, and making sure that patients get medication in the customized fashion that they get at home—we don't put in default medication regimens. We also have a metric to make sure patients are not getting contraindicated medication."

Close monitoring of the metrics impacts patient care, he says.

"Every time an order is placed for a Parkinson's medication, we make sure the order is placed in a customized fashion. We track the number of customized orders versus non-customized orders, and we try to correct inappropriate orders in real time. With contraindicated medications, we follow up when these medications are ordered. We work very hard to prohibit the ordering of these medications for Parkinson's patients."

3. Metrics evaluation and implementation of action plans
 

When care teams find that metrics performance needs to be improved for patients, the hospital's Disease-Specific Committee for Parkinson's Disease develops improvements through implementation of action plans, Azmi says.

"Sometimes, there is an issue in a part of the hospital, so we educate the staff in that area. There may be an instance when the pharmacy needs to develop options when certain medications are ordered. Through the disease-specific committee, we have been able to look at the data, assess it, then come up with plans to improve the compliance," he says.

4. Education
 

Staff throughout the hospital has received education and training for the strict medication adherence protocol, including physicians, advanced practice practitioners, nurses, physical therapists, radiation technologists, and pharmacists.

"Everyone needs to be aware about the importance of medication and avoiding contraindicated medication," Azmi says.

The education and training have been provided in several formats such as webinars, surveys, and a variety of grand rounds for nurses and physicians. "It's an ongoing educational process—it must be continuous because managing these patients poses problems on a continuous basis," he says.

The key to success of the strict medication adherence protocol has been the hospital-wide approach, Azmi says.

"It's a cliché to say it takes a village to raise a child, but it takes an entire hospital to care for one patient. Everything we do for this patient population translates to the entire hospital. This protocol makes us better, and it takes many people from different parts of the hospital—from physicians, to nursing, to physical therapy, to the pharmacy, to regulatory staff, to quality officers. It is truly an interdisciplinary effort to launch an initiative like this throughout the hospital. But it translates into better patient care and financial savings for the hospital."

Azmi is the co-author of a 2018 book about Parkinson's care in the hospital setting, Parkinson's Disease for the Hospitalist: Managing the Complex Care of a Vulnerable Population.