It is estimated that by the year 2050, about 79 million individuals in the United States will be older than 65 years. Older adults are the fastest growing segment in the U.S. population. Cancer incidence is projected to rise as the general population ages, and is a leading cause of mortality in the elderly. Because of advances in modern medicine, life expectancy has increased significantly and cancer has become a chronic disease. Cancer is a major health concern in the United States, yet information about the services and programs for older adults with cancer are still limited. The current health care system has undergone major changes regarding reimbursement. Inpatient lengths of stay have been significantly reduced under curtailed reimbursement, and the burden of care has shifted to outpatient and home care. The older adult population has unique needs that pose a tremendous challenge to health care professionals. Designing a comprehensive plan of care after hospital discharge should address the behavioral and functional issues prevalent among elderly patients with cancer, such as medication adherence and home safety. Furthermore, an understanding of specialized programs or geriatric resources (involving a multidisciplinary approach) is essential to optimizing health outcomes for this important patient population.
Medication Adherence among Elderly Cancer Patients
H.T. is a 65-year-old woman who has been newly diagnosed with chronic myelocytic leukemia (CML) in its chronic phase. Her medical history is significant for hypertension, diet-controlled diabetes, and depression. She received patient education on her diagnosis and the intended therapies. She does not yet fully comprehend her diagnosis and is overwhelmed at the prospect of cancer treatments. She lives alone in an apartment with no immediate family. She drives a long way to her medical appointments.
She started treatment with an oral antineoplastic agent, and experienced nausea with the medication despite antiemetic therapy. She returned to the clinic a week later complaining of nausea and vomiting; her serum potassium level was 3.
Scope of Problem
As the nature of cancer therapy shifts from acute to chronic care, medication adherence or compliance has become an increasingly important concern. Compliance or adherence refers to the ability to maintain health-promoting regimens, whether it involves taking a medication, performing an exercise program, or carrying out lifestyle changes. Some experts assign a subtle difference to the meaning of compliance and adherence but they will be used interchangeably for the purpose of this chapter.
Because the elderly often have multiple comorbidities, an older adult takes, on average, three to twelve prescription drugs and one to four nonprescription drugs per year. However, it is estimated that only about 60% take their prescribed medications properly. There are currently more than 20 oral agents in the cancer armamentarium and dozens more in the pipeline. With the significant increase in the use of oral agents for treating cancer or otherwise, there is also a concurrent potential increase in the risk of nonadherence among the elderly. Nonadherence to oral medications is a barrier to optimal therapy and can impair health through delayed healing, promote disease recurrence, or even hasten death. Nonadherence is not only an impediment to the full therapeutic benefit of the regimen but is also associated with increased health care costs due to frequent physician visits and hospitalizations.
Factors Involved in Nonadherence
The financial impact of medication nonadherence to the U.S. health care industry is estimated to be $100 billion per year. To ensure safety, quality of care, and improved treatment outcomes, it is imperative that patients adhere to a medication regimen. Nonadherence can have crucial implications to oncology. Nonadherence to a drug regimen is a multifaceted issue and involves three major variables: patient, physician, and treatment.
Patient variables relate to individual factors that are associated with medication adherence such as physical and cognitive decline, intentional nonadherence, inadequate support system, lack of belief about treatment, and psychological illnesses, particularly depression. Memory deficits, poor visual acuity, and diminished manual dexterity can also contribute to medication nonadherence. The elderly may have challenges understanding complex regimens and therefore may have difficulty complying with the directions as instructed. Furthermore, nonadherence can be intentional; the reasons for this are complex. A study on chronically ill patients who were starting a new medication found that a third did not comply with the prescribed regimen; for 50% of these, the nonadherence was intentional because of medication side effects. Knowledge and beliefs about health can also influence medication-taking behavior, although these variables have yet to be validated in research studies. Patients may adhere to the medication regimen if they believe that the medication will help and that the potential benefit outweighs the risk. In addition, mood disorders such as depression can also influence medication adherence. Depression is a common comorbid chronic illness in older adults that is underdiagnosed and undertreated. Compared to patients who are mentally stable, the medication nonadherence rate is 27% higher among depressed patients. Physician factors refer to the patient-physician interaction. The relationship between the doctor and the patient, the communication skills involved, and the physician’s cultural competence, as well as his or her comfort in dealing with older patients, all contribute to adherence to therapy. Poor patient-provider communication, inadequate discussion of side effects, and lack of patient understanding about the effectiveness of treatment may foster dissatisfaction and mistrust that can hamper effective medication adherence. Another problem is the lack of awareness and recognition by health care providers of the existing problem of medication nonadherence.
Treatment variables refer to the medical and economic considerations that can affect medication adherence such as side effects, duration of treatment, medication costs, polypharmacy, and complexity of drug regimen. Because of chronic conditions, the elderly tend to be on multiple medications. Medication side effects are a major reason that older adults skip doses or stop taking their medications. A study on adjuvant therapy with tamoxifen revealed that women were four times more likely to be nonadherent to the regimen if they experienced side effects. Thirty-five percent of older adults who took five or more medications were prone to adverse reactions. Likewise, patients who are on therapy for an extended period have a high rate of discontinuation. The higher the number of medications, the less likely the elderly will adhere to therapy. The elderly take, on average, four to seven prescription medications, three over-the-counter medications and one herbal supplement. Polypharmacy and multiple medication doses required per day create a complex of medication regimen and increase the risk of drug reactions among the elderly.
Solutions to the Problem
Patient education is important to promoting medication adherence in the elderly. A specific set of educational methods should be tailored to their learning needs, and assessment should focus on their memory, attention, and executive functioning. There are several aids to medication planning and organization. Methods that were found to be beneficial in promoting medication adherence include utilization of a timed pill box, placing containers in a familiar location, taking medications in synchrony with meals/bedtime, getting reminders from others, and using a check-off list or written instructions. Written instructions in large letters or bullet and list format seem beneficial. When discussing medications, it is likewise helpful to provide general information first, followed by how to take the medicine, the outcomes or side effects to watch for, and signs or symptoms of when to call the doctor. Memory-enhancing methods such as medication schedules, refrigerator medication charts, electronic reminders or alarms, or an electronic medication-dispensing device can also enhance patient medication adherence. Medication cards that list current medications can heighten drug compliance; this list can be shared with other prescribing providers who can update and review drug regimens at each clinic visits.
Refilling prescriptions can also be challenging for the older adults. A system to assist in procuring or refilling prescriptions such as a mail-order pharmacy, pharmacy automatic-refill service, or telephone reminder calls can be very beneficial. Modified medication containers or blister packs may make it easier for those who are physically challenged to open medication containers. The pharmacy can be a good resource when choosing alternatives for preparing medications for administration, such as utilizing tablets that are easier to break or providing correct medication dosages that don’t require breaking. A comprehensive pharmacy medication adherence program or system that includes patient education, pharmacy consultation, and follow-up can enable elderly patients to adhere more closely to their medication regimens. Pharmacy reviews to decrease polypharmacy, such as the Beers criteria for potentially inappropriate medication use, can be a helpful guide when considering medications that should be avoided in patients age 65 and older and can identify adverse drug interactions.
The importance of engaging the help of family members or supportive caregivers can never be overemphasized. Family members and caregivers provide emotional and regimen-specific support. They provide important clues and information that are valuable when considering the functional status, cognitive capacity, health maintenance, and medication habits of the aging population.
Overall, there is no single best method to promote medication adherence in the older adult population. A multifaceted approach is warranted ( Table 25-1 for a summary of practical recommendations to improve medication adherence in the elderly).
| Factors associated with nonadherence to oral medications | Helpful recommendations for increasing adherence |
|---|---|
| Patient-related variables | |
| Cognitive deficits | Use of memory cues (taking medications based on routine or synchrony with meals/bedtime); Memory -enhancing methods or devices (pre-poured or timed pill box; utilizing a medication dispensing service; automatic dispensers with voice-activated message; telephone call reminders; placing containers in a familiar location; medication calendar or charts; wristwatch with alarms; medication diary; dose-reminder cards) |
| Physical deficits | Use of blister packs, or easy-open containers/non-childproof containers; consult with pharmacy regarding medication modification (correct dose of medications, easy-to-break tablets) |
| Other: depression, intentional nonadherence, lack of belief about treatment, inadequate support system. | Assess and treat depression; explore health concerns for noncompliance; reinforce benefits of therapy; discuss the danger of missed medications; refer to social worker or discharge planner on community resources; enlist help of family members/caregivers; annual physical exams |
| Physician-related variables | |
| Poor patient-provider relationship or communication | Regular contact and consistent patient support (nonjudgmental attitude, active listening, reinforce adherent behaviors, cultural sensitivity, convenient follow-up schedules) |
| Provide patient education and periodic drug review (medication side effects, benefits of therapy, asking for feedback, keeping messages simple, providing informational resources) | |
| Treatment-related variables | |
| – Side effects | – Modify regimen to reduce adverse effects |
| – Complexity of regimen | – Simplify the regimen and dosing schedule:
|
| – Medication costs | -Seek assistance with procuring medications; learn about insurance coverage; consult with other physicians about availability of drug samples; use of generic drugs; participate in drug company programs; refer to social worker regarding Medicare prescription coverage ( www.medicare.gov/MedicareReform ). Review if drug regimen is efficacious and economical. |
| – Polypharmacy | – Medication review semi-annually; check duplicate drug therapies; use combination drugs or alternative routes; screen for drug interactions; create an updated medication list to share to providers; apply Beers criteria on medication review. |
Health Care Providers’ Role
The physician’s role is central and key to successful medication adherence in the elderly. The physician should constantly assess personal characteristics (physical/cognitive/emotional skills), relationship orientation, and the way a patient absorbs and process information (self-efficacy), because all patients are unique. Listening to the patient is very important. It helps to have comfort in dealing with older patients. Enhanced patient-provider communication fosters adherence by creating trust and improves patient satisfaction with care. It is essential to have regular contact and consistent patient support at all levels of care. During a patient clinic visit, it is important for providers to screen for potential adverse drug interactions and identify any medications of concern. It is necessary to have an updated list of all medications including dose frequency and to have the patient provide this list to other prescribing providers when necessary.
Elderly patients require a substantial need for more information when starting a new medication. It is necessary keep the information simple and clear, both in verbal and written form. Start with what the patient already knows and discuss the names of the drugs being ordered and its effect. Always provide time for questions. Physicians should carefully explain information regarding treatments and should reinforce disease characteristics, risks and benefits of treatments, and the proper use of medication. It is important to discuss medication side effects from the start of treatment so that patients may know what to expect and be better able to deal with adverse reactions to therapy. An understanding of how some medications might have different effects on people of various ethnicities, as well as a knowledge of age-related changes in metabolism and drug interactions are essential.
Also, it is imperative to identify barriers to adherence; questioning techniques about medication-taking behaviors should be nonjudgmental and may include statements such as “How do you take your medications?” “Do you stop taking medication when you feel better/when you feel worse?” and “Are you having difficulty taking your medications daily?” It is also helpful to inquire about situations that may have an impact on medication adherence such as missed doses and what the patient should do in the situation of a missed dose. Caregivers should be involved in the plan of care. They can reinforce adherent behaviors. Getting feedback at each clinic discussion can help to uncover and address issues that can have important implications to medication adherence and overall health. If the patient has difficulty understanding a particular medication at a previous clinic encounter, then reviewing the drug again at the next visit would be very helpful to encouraging adherence. It is also beneficial to discuss special instructions such as taking medication with food or the proper way to use an inhaler, as well as side effects to monitor or report.
Assistance Programs
It is a known fact that the more costly the medication, the less likely that older adults will procure the medication or adhere to a regimen that includes it. Lack of funds, especially at the end of the month, is a major factor in why older adults have difficulty filling their prescriptions. The out-of-pocket costs, high copayment, or a lack of prescription drug coverage can create a tremendous financial burden for chronically ill adults and can be a major barrier to medication adherence.
Helpful suggestions to ease medication procurement for the elderly include the use of drug samples from prescribing physicians, participation in copayment assistance programs from pharmaceutical corporations, and pharmacy consultation on utilizing generic instead of brand name drugs. Patients can be referred to a social worker to navigate the system or to help them obtain Medicare or other insurance coverage. Several states have pharmacy assistance programs that help eligible persons pay for their prescription drugs.
H.T. had been unable to fill her antiemetic prescription because of a high copayment for drug regimens. She had thought of stopping therapy entirely, because of her limited income, but had reluctantly refilled only her oral antineoplastic agent and not the antiemetic medication. At this clinic visit, an antiemetic and replacement with intravenous potassium were ordered. The oncologist explored her economic challenges to filling her prescriptions, assessed her self-care skills and her current stressors or depression, and offered encouragement and support to maintain a proactive stance in her medical oncology care. During this clinic visit, the physician modified her antiemetic regimen; a cheaper alternative prescription to manage delayed nausea was ordered, and a drug sample was given. She was also referred to the nurse navigator and social worker regarding local/national cancer support groups or other resources that she might find helpful. She was also informed about psychosocial assistance when necessary. A copay assistance program was also explored and a pharmaceutical drug representative was contacted.
Specific information regarding expected side effects, adverse reactions of the medication regimen, and commonly encountered drug-drug interactions were reiterated. Her questions were answered and she feels satisfied to continue with her cancer therapy. The oncologist also collaborated with the patient’s primary care doctor and discussed what they would do to comanage this patient’s care effectively.
Scope of Problem
As the nature of cancer therapy shifts from acute to chronic care, medication adherence or compliance has become an increasingly important concern. Compliance or adherence refers to the ability to maintain health-promoting regimens, whether it involves taking a medication, performing an exercise program, or carrying out lifestyle changes. Some experts assign a subtle difference to the meaning of compliance and adherence but they will be used interchangeably for the purpose of this chapter.
Because the elderly often have multiple comorbidities, an older adult takes, on average, three to twelve prescription drugs and one to four nonprescription drugs per year. However, it is estimated that only about 60% take their prescribed medications properly. There are currently more than 20 oral agents in the cancer armamentarium and dozens more in the pipeline. With the significant increase in the use of oral agents for treating cancer or otherwise, there is also a concurrent potential increase in the risk of nonadherence among the elderly. Nonadherence to oral medications is a barrier to optimal therapy and can impair health through delayed healing, promote disease recurrence, or even hasten death. Nonadherence is not only an impediment to the full therapeutic benefit of the regimen but is also associated with increased health care costs due to frequent physician visits and hospitalizations.
Factors Involved in Nonadherence
The financial impact of medication nonadherence to the U.S. health care industry is estimated to be $100 billion per year. To ensure safety, quality of care, and improved treatment outcomes, it is imperative that patients adhere to a medication regimen. Nonadherence can have crucial implications to oncology. Nonadherence to a drug regimen is a multifaceted issue and involves three major variables: patient, physician, and treatment.
Patient variables relate to individual factors that are associated with medication adherence such as physical and cognitive decline, intentional nonadherence, inadequate support system, lack of belief about treatment, and psychological illnesses, particularly depression. Memory deficits, poor visual acuity, and diminished manual dexterity can also contribute to medication nonadherence. The elderly may have challenges understanding complex regimens and therefore may have difficulty complying with the directions as instructed. Furthermore, nonadherence can be intentional; the reasons for this are complex. A study on chronically ill patients who were starting a new medication found that a third did not comply with the prescribed regimen; for 50% of these, the nonadherence was intentional because of medication side effects. Knowledge and beliefs about health can also influence medication-taking behavior, although these variables have yet to be validated in research studies. Patients may adhere to the medication regimen if they believe that the medication will help and that the potential benefit outweighs the risk. In addition, mood disorders such as depression can also influence medication adherence. Depression is a common comorbid chronic illness in older adults that is underdiagnosed and undertreated. Compared to patients who are mentally stable, the medication nonadherence rate is 27% higher among depressed patients. Physician factors refer to the patient-physician interaction. The relationship between the doctor and the patient, the communication skills involved, and the physician’s cultural competence, as well as his or her comfort in dealing with older patients, all contribute to adherence to therapy. Poor patient-provider communication, inadequate discussion of side effects, and lack of patient understanding about the effectiveness of treatment may foster dissatisfaction and mistrust that can hamper effective medication adherence. Another problem is the lack of awareness and recognition by health care providers of the existing problem of medication nonadherence.
Treatment variables refer to the medical and economic considerations that can affect medication adherence such as side effects, duration of treatment, medication costs, polypharmacy, and complexity of drug regimen. Because of chronic conditions, the elderly tend to be on multiple medications. Medication side effects are a major reason that older adults skip doses or stop taking their medications. A study on adjuvant therapy with tamoxifen revealed that women were four times more likely to be nonadherent to the regimen if they experienced side effects. Thirty-five percent of older adults who took five or more medications were prone to adverse reactions. Likewise, patients who are on therapy for an extended period have a high rate of discontinuation. The higher the number of medications, the less likely the elderly will adhere to therapy. The elderly take, on average, four to seven prescription medications, three over-the-counter medications and one herbal supplement. Polypharmacy and multiple medication doses required per day create a complex of medication regimen and increase the risk of drug reactions among the elderly.
Solutions to the Problem
Patient education is important to promoting medication adherence in the elderly. A specific set of educational methods should be tailored to their learning needs, and assessment should focus on their memory, attention, and executive functioning. There are several aids to medication planning and organization. Methods that were found to be beneficial in promoting medication adherence include utilization of a timed pill box, placing containers in a familiar location, taking medications in synchrony with meals/bedtime, getting reminders from others, and using a check-off list or written instructions. Written instructions in large letters or bullet and list format seem beneficial. When discussing medications, it is likewise helpful to provide general information first, followed by how to take the medicine, the outcomes or side effects to watch for, and signs or symptoms of when to call the doctor. Memory-enhancing methods such as medication schedules, refrigerator medication charts, electronic reminders or alarms, or an electronic medication-dispensing device can also enhance patient medication adherence. Medication cards that list current medications can heighten drug compliance; this list can be shared with other prescribing providers who can update and review drug regimens at each clinic visits.
Refilling prescriptions can also be challenging for the older adults. A system to assist in procuring or refilling prescriptions such as a mail-order pharmacy, pharmacy automatic-refill service, or telephone reminder calls can be very beneficial. Modified medication containers or blister packs may make it easier for those who are physically challenged to open medication containers. The pharmacy can be a good resource when choosing alternatives for preparing medications for administration, such as utilizing tablets that are easier to break or providing correct medication dosages that don’t require breaking. A comprehensive pharmacy medication adherence program or system that includes patient education, pharmacy consultation, and follow-up can enable elderly patients to adhere more closely to their medication regimens. Pharmacy reviews to decrease polypharmacy, such as the Beers criteria for potentially inappropriate medication use, can be a helpful guide when considering medications that should be avoided in patients age 65 and older and can identify adverse drug interactions.
The importance of engaging the help of family members or supportive caregivers can never be overemphasized. Family members and caregivers provide emotional and regimen-specific support. They provide important clues and information that are valuable when considering the functional status, cognitive capacity, health maintenance, and medication habits of the aging population.
Overall, there is no single best method to promote medication adherence in the older adult population. A multifaceted approach is warranted ( Table 25-1 for a summary of practical recommendations to improve medication adherence in the elderly).
| Factors associated with nonadherence to oral medications | Helpful recommendations for increasing adherence |
|---|---|
| Patient-related variables | |
| Cognitive deficits | Use of memory cues (taking medications based on routine or synchrony with meals/bedtime); Memory -enhancing methods or devices (pre-poured or timed pill box; utilizing a medication dispensing service; automatic dispensers with voice-activated message; telephone call reminders; placing containers in a familiar location; medication calendar or charts; wristwatch with alarms; medication diary; dose-reminder cards) |
| Physical deficits | Use of blister packs, or easy-open containers/non-childproof containers; consult with pharmacy regarding medication modification (correct dose of medications, easy-to-break tablets) |
| Other: depression, intentional nonadherence, lack of belief about treatment, inadequate support system. | Assess and treat depression; explore health concerns for noncompliance; reinforce benefits of therapy; discuss the danger of missed medications; refer to social worker or discharge planner on community resources; enlist help of family members/caregivers; annual physical exams |
| Physician-related variables | |
| Poor patient-provider relationship or communication | Regular contact and consistent patient support (nonjudgmental attitude, active listening, reinforce adherent behaviors, cultural sensitivity, convenient follow-up schedules) |
| Provide patient education and periodic drug review (medication side effects, benefits of therapy, asking for feedback, keeping messages simple, providing informational resources) | |
| Treatment-related variables | |
| – Side effects | – Modify regimen to reduce adverse effects |
| – Complexity of regimen | – Simplify the regimen and dosing schedule:
|
| – Medication costs | -Seek assistance with procuring medications; learn about insurance coverage; consult with other physicians about availability of drug samples; use of generic drugs; participate in drug company programs; refer to social worker regarding Medicare prescription coverage ( www.medicare.gov/MedicareReform ). Review if drug regimen is efficacious and economical. |
| – Polypharmacy | – Medication review semi-annually; check duplicate drug therapies; use combination drugs or alternative routes; screen for drug interactions; create an updated medication list to share to providers; apply Beers criteria on medication review. |
Health Care Providers’ Role
The physician’s role is central and key to successful medication adherence in the elderly. The physician should constantly assess personal characteristics (physical/cognitive/emotional skills), relationship orientation, and the way a patient absorbs and process information (self-efficacy), because all patients are unique. Listening to the patient is very important. It helps to have comfort in dealing with older patients. Enhanced patient-provider communication fosters adherence by creating trust and improves patient satisfaction with care. It is essential to have regular contact and consistent patient support at all levels of care. During a patient clinic visit, it is important for providers to screen for potential adverse drug interactions and identify any medications of concern. It is necessary to have an updated list of all medications including dose frequency and to have the patient provide this list to other prescribing providers when necessary.
Elderly patients require a substantial need for more information when starting a new medication. It is necessary keep the information simple and clear, both in verbal and written form. Start with what the patient already knows and discuss the names of the drugs being ordered and its effect. Always provide time for questions. Physicians should carefully explain information regarding treatments and should reinforce disease characteristics, risks and benefits of treatments, and the proper use of medication. It is important to discuss medication side effects from the start of treatment so that patients may know what to expect and be better able to deal with adverse reactions to therapy. An understanding of how some medications might have different effects on people of various ethnicities, as well as a knowledge of age-related changes in metabolism and drug interactions are essential.
Also, it is imperative to identify barriers to adherence; questioning techniques about medication-taking behaviors should be nonjudgmental and may include statements such as “How do you take your medications?” “Do you stop taking medication when you feel better/when you feel worse?” and “Are you having difficulty taking your medications daily?” It is also helpful to inquire about situations that may have an impact on medication adherence such as missed doses and what the patient should do in the situation of a missed dose. Caregivers should be involved in the plan of care. They can reinforce adherent behaviors. Getting feedback at each clinic discussion can help to uncover and address issues that can have important implications to medication adherence and overall health. If the patient has difficulty understanding a particular medication at a previous clinic encounter, then reviewing the drug again at the next visit would be very helpful to encouraging adherence. It is also beneficial to discuss special instructions such as taking medication with food or the proper way to use an inhaler, as well as side effects to monitor or report.
Assistance Programs
It is a known fact that the more costly the medication, the less likely that older adults will procure the medication or adhere to a regimen that includes it. Lack of funds, especially at the end of the month, is a major factor in why older adults have difficulty filling their prescriptions. The out-of-pocket costs, high copayment, or a lack of prescription drug coverage can create a tremendous financial burden for chronically ill adults and can be a major barrier to medication adherence.
Helpful suggestions to ease medication procurement for the elderly include the use of drug samples from prescribing physicians, participation in copayment assistance programs from pharmaceutical corporations, and pharmacy consultation on utilizing generic instead of brand name drugs. Patients can be referred to a social worker to navigate the system or to help them obtain Medicare or other insurance coverage. Several states have pharmacy assistance programs that help eligible persons pay for their prescription drugs.
H.T. had been unable to fill her antiemetic prescription because of a high copayment for drug regimens. She had thought of stopping therapy entirely, because of her limited income, but had reluctantly refilled only her oral antineoplastic agent and not the antiemetic medication. At this clinic visit, an antiemetic and replacement with intravenous potassium were ordered. The oncologist explored her economic challenges to filling her prescriptions, assessed her self-care skills and her current stressors or depression, and offered encouragement and support to maintain a proactive stance in her medical oncology care. During this clinic visit, the physician modified her antiemetic regimen; a cheaper alternative prescription to manage delayed nausea was ordered, and a drug sample was given. She was also referred to the nurse navigator and social worker regarding local/national cancer support groups or other resources that she might find helpful. She was also informed about psychosocial assistance when necessary. A copay assistance program was also explored and a pharmaceutical drug representative was contacted.
Specific information regarding expected side effects, adverse reactions of the medication regimen, and commonly encountered drug-drug interactions were reiterated. Her questions were answered and she feels satisfied to continue with her cancer therapy. The oncologist also collaborated with the patient’s primary care doctor and discussed what they would do to comanage this patient’s care effectively.
H.T. had been unable to fill her antiemetic prescription because of a high copayment for drug regimens. She had thought of stopping therapy entirely, because of her limited income, but had reluctantly refilled only her oral antineoplastic agent and not the antiemetic medication. At this clinic visit, an antiemetic and replacement with intravenous potassium were ordered. The oncologist explored her economic challenges to filling her prescriptions, assessed her self-care skills and her current stressors or depression, and offered encouragement and support to maintain a proactive stance in her medical oncology care. During this clinic visit, the physician modified her antiemetic regimen; a cheaper alternative prescription to manage delayed nausea was ordered, and a drug sample was given. She was also referred to the nurse navigator and social worker regarding local/national cancer support groups or other resources that she might find helpful. She was also informed about psychosocial assistance when necessary. A copay assistance program was also explored and a pharmaceutical drug representative was contacted.
Specific information regarding expected side effects, adverse reactions of the medication regimen, and commonly encountered drug-drug interactions were reiterated. Her questions were answered and she feels satisfied to continue with her cancer therapy. The oncologist also collaborated with the patient’s primary care doctor and discussed what they would do to comanage this patient’s care effectively.
Home Safety
Homecare Services
The older adult population’s cancer illness experience and needs differ substantially from those of younger age groups because of multiple chronic medical conditions that often compound the oncologic diagnosis. The current health care system, typified by shorter hospital stays and an increased shift of cancer treatments from hospital to ambulatory settings, has concomitantly caused a great challenge for older adults by making it necessary for them to cope in the home setting with the physical and psychosocial difficulties associated with cancer. Homecare for older adults with cancer may necessitate a multidisciplinary approach, requiring integration, continuity of care, and coordination of a number of service disciplines such as social workers, pharmacists, physical therapy (PT), speech therapy (ST), or occupational therapy (OT). A description of these skilled and ancillary services can be found in Table 25-2 . Several patient-safety issues that can affect health outcomes upon discharge relate to issues including but not limited to medication adherence, living situation, and physical and cognitive functioning. Much of the decision is left to clinicians’ individual assessment and clinical judgment when it comes to identifying characteristics of patients needing homecare referral, as Medicare regulations only dictate that patients be homebound and have a need for skilled assistance. In addition, situational variables that present special challenges to recovery, health maintenance, and safety for this high-risk population include transportation, social support, maintaining independence, and financial resources. To be eligible for Medicare reimbursement, home health services should be deemed medically necessary by a physician and should be provided on an intermittent or part-time basis. Medicare law prohibits reimbursement for ancillary services unless a skilled service is initially ordered and provided. Physicians can refer to home health services or services may be requested by a family member or patients themselves.
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