How A Designated Care Coordinator Or Patient Navigator Can Save Lives and Help Bridge the Gap Between Patients, Physicians And Pharmacists

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A Vial of Life Kit hangs on a refrigerator. The kit, funded by a non-profit effort, is comprised of a plastic bag filled with vital medical information. In case of emergency, emergency personnel can locate medical information. A sticker at the person's front door directs first responders where to locate the kit.
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LIVINGSTON, NJ - A young woman vacationing in Hollywood, Florida was found unconscious and unresponsive in her hotel bed. Fervent attempts to revive the 39-year old victim failed, and she was pronounced dead at an area hospital. An autopsy uncovered 11 drugs in her system including Valium, which was further enhanced by the sedative, Chloral Hydrate. That, combined with a doctor falsifying prescriptions and writing prescriptions for individuals close to the victim, who were also feeding the victim the drugs, was a prescription itself for disaster.

A housekeeper and masseuse walked into the bedroom of their 28-year old employer, and found him unconscious in his Soho, New York apartment. Like the case of the first victim above, they initiated CPR, but failed. The city's chief medical examiner said the victim died from prescription drug abuse, from mixing six drugs including the pain medications Oxycodone and Hydrocodone as well as Valium along with insomnia, anti-histamine, and anti-anxiety medications. No one was aware the victim was a frequent "doctor shopper", bouncing from physician to physician, who unknowingly helped him to construct his prescription arsenal.

A primary care physician and cardiologist excused himself for the rest room during a house call at one of his patient's homes. He had just administered Propofol, a powerful anesthetic drug to help ease his patient's insomnia. Instead, during the doctor's brief departure, his 50-year old patient was pushed into eternal slumber. Attempts at CPR fizzled, and help was delayed without a landline in the home and the doctor's uncertainty of the exact address of his patient's estate. Typically a drug used during general anesthesia, the victim developed a penchant for it, and a tolerance to other drugs. He referred to it as his "milk" and despite the doctor attempting to lower and eliminate the dosage and substitute it with the hypnotic and muscle-relaxing alternatives of Lorazepam and Midazolam, the patient allegedly demanded it from the doctor, who relented. This case was another disaster waiting to happen because of the victim's long-term addiction history combined with Propofol, which interacted with five other drugs ranging from stimulants to sedatives, and was found in the victim's body upon autopsy.

A shocked mother found her 32-year old daughter unconscious in their Los Angeles bathroom. She tried CPR, and even when help arrived, it was too late. The victim had apparently been ill for weeks with pneumonia, yet continued to defer doctors' appointments. The coroner found drug intoxication and iron-deficient anemia along with the pneumonia. Following her death, it was learned that an astute pharmacist refused to fill prescriptions for the entire household because of excessive prescriptions purchased. The victim had been prescribed nearly 200 pills a month by doctors from January 2008 through August 2009. In an ironic twist of déjà vu, the mother found her son-in-law dead in the same residence nearly five months later of a suspected drug overdose. The cause of his death is still under investigation.

A 38-year old man with a history of drug addiction and overdose collapsed in front of his mother in the California apartment they shared. He had supposedly been trying to stay away from drugs, and had been feeling ill for a few days. Despite CPR, he did not survive. Investigations have uncovered another addiction: the victim was hooked on doctor and pharmacy shopping. He bought nearly 533 pills under aliases the month before his death. Among his stash of pills were muscle relaxants and anti-psychotics, aas well as Valium and Vicodan. Investigators uncovered a darker secret: a fictitious prescription slip found in his home, concocted by a forger. The victim also shopped in shady places, including purchasing Oxycontin from a prescription drug ring, and gleaning thousands of pills during his last year of life by bouncing between doctors' offices and emergency rooms.

Could a coordinated caregiver have been an important player to keep record of the multiple prescriptions and doctors for the above listed cases of Anna Nicole Smith, Heath Ledger, Michael Jackson, Brittany Murphy and Corey Haim, and could a designated person have helped to steer these young lives from premature death?

We will never know for sure, but a designated coordinated care professional or patient navigator, could not have hurt in these situations.

What do these celebrity cases have in common with many Americans, including the elderly, who have easily fallen into the trap of multiple prescriptions and doctors, which when not tracked, can lead to harmful results?

The issue of doctor and pharmacy shopping is rampant in the United States, and the result of this type of shopping habit is devastating. According to a CNN report, prescription drug poisoning is on the rise, with hospitalizations up nearly 65 percent between 1996 and 2006, due to prescription opiods, sedatives, and tranquilizers.

"This idea of doctor and pharmacy shopping is common out there, and that is a problem waiting to happen," said Eddie Bubar, a pharmacist for 30 years, and owner of the independent pharmacy, Eddie's Pharmacy in West Hollywood, California. Bubar was the pharmacist who flagged Brittany Murphy's household when he spotted a trend of severe prescription abuse in the household.

"If this is happening with celebrities, think about an average 80-year old living alone," Heidi Schnapp remarked. Schnapp is co-founder of LMR Elder Care, a geriatric care management firm based in Livingston., New Jersey.

Schnapp's statement raises an important point. For a senior who may not have a family member to help organize their medical information if they are incapable, it may lead to devastating results.

Information from multiple doctors and numerous prescriptions may become jumbled if not properly tracked. This can lead to issues such as duplication of services or prescriptions, and drug interactions, allergies, and addictions, which can lead to death in some cases.

Some patients may innocently forget to share information between one doctor and another regarding new prescriptions and test results. Others may knowingly conceal facts about their care in order to deceive doctors and pharmacists, and manipulate the system.

"It's the responsibility of both the doctor and the patient to share information with one another," said Candis Cohen, the spokesperson for the Medical Board of California. "A person's physicians should be communicating with one another and patients should make sure this happens. It's important to stay on top of a person's whole health."

The Medical Board of California oversees the licensing and disciplining of physicians in the State of California. In the case of Michael Jackson, the Medical Board has disciplined his physician, Conrad Murray. California's Office of the Attorney General represented the Medical Board of California in this case, and turned to the Los Angeles Superior Court in March 2010 on their behalf, to restrict Murray from practicing. In February 2010, the Los Angeles County District Attorney's Office filed criminal charges against Murray for involuntary manslaughter. "Murray administered a lethal dose of Propofol, as well as other drugs to Michael Jackson," Attorney General Edmund Brown, Jr. stated. "We will argue in court that Murray was reckless in giving Jackson such a dangerous drug and has demonstrated a serious lack of judgment that should prohibit him from practicing medicine."

According to a statement on the Los Angeles District Attorney's Office website, Murray could be imprisoned for four years for involuntary manslaughter. Physician experts and the courts need to sort through the case to determine the outcome.

Murray, whose office address is in Las Vegas, has had restrictions placed on his license in California, Texas, Nevada, Hawaii and other states where Murray is licensed. He is not permitted to administer Propofol or any heavy sedatives to patients. He was released on bail, forced to surrender his passport, and now awaits his preliminary hearing on August 23, about 14 months following Jackson's unexpected death.

Regarding Michael Jackson's death, Lisa Bayer, President of LMR Elder Care said, "Despite Jackson's fame, or perhaps because of his celebrity, those around him did not ask enough or the right questions and therefore he lacked 'coordinated care.' Had his personal physician had all of the information available to him it's possible that he may have made different decisions in the days and hours that led to the administration of the drug that caused his death."

In this day and age, it is important for physicians, pharmacists and patients to take a proactive approach in a patient's care, and work together, for a range of obvious reasons. With the division of primary care physicians, medical specialists, pharmacists, mail-order prescription services, and over-the-counter remedies and supplements, it requires organization, through a coordinated care approach, to keep it all together.

"We talk to doctors all day long," said Bubar, whose pharmacy works constantly with physicians and patients, and can print out prescription histories for his customers on request. Bubar said controls have been stepped up for pharmacists in California, who can see by computer if controlled substances are purchased through insurance. It can be tracked no matter what pharmacy fills the prescription. Drugs purchased through an insurance plan cannot be refilled within less than 30 days and claims are rejected.

Cash customers offer a challenge to pharmacists, but Bubar's radar perked up from his years of expertise in regard to Brittany Murphy's household. He said although Murphy's husband and her mother were excellent cash customers, his pharmacy was wary about the activity and cut them off, 6 to 8 months before Murphy's death.

"In these days with a good significant client, some may look the other way," Bubar said. "To us at the pharmacy, it was a very bad situation, or one that would only get worse."

Vigilance such as Bubar's is a significant step in helping to close the gap, and improving a patient's healthcare.

Schnapp said it could present a challenge when most people average 5 or 6 specialists for their care. She said the danger lies when things are not communicated between one specialist and another, and individuals have prescriptions at different pharmacies.

"A person's primary care doctor needs to know everything," Schnapp said. "It all ties together when a care coordinator works together with a primary care doctor, and they can do their job."

According to a study and pilot program performed by UMDNJ (University of Medicine and Dentistry of New Jersey), and with funding from the Overlook Hospital Foundation, a patient navigator to coordinate care is an integral role in the patient/physician relationship.

"The patient-centered medical home (PCMH) is widely advocated as a way to help reform the U.S. healthcare system into one that is more accessible, effective, safer and economical," the authors of the UMDNJ study wrote. "Central to the PCMH concept is care that is 'coordinated or integrated across all elements of the complex healthcare system and the patient community'. This is crucial since fragmented care leads to unnecessary services, duplication of information gathering and testing, and poorer health outcomes."

Jeanne M. Ferrante, MD, Deborah Cohen, PHD, and Jesse Crossan, PHD, who wrote the article and headed the study, said New Jersey is ranked one of the most fragmented in the nation when it comes to healthcare.

The UMDNJ pilot program was comprised of a social worker to act as patient navigator and liaison for four primary care physicians. The patient navigator in the program oversaw the medical services provided to 75 patients, many geriatric cases. Patients chosen for the program had more complex health situations, which were ideal candidates for a patient navigator. The patient navigator interacted directly with the patient and physician, and bypassed other players in the physicians' practices.

At the conclusion of the study, patients and physicians agreed the patient navigator "relieved their own or their family members' burdens." Patients and physicians described the service as "helpful" but reported they were unwilling to pay for such a service.

Ferrante, Cohen and Crossan surmised nonetheless, "Patient navigation services are useful for patients who need emotional support and coordination of social services and complex referrals. These services are typically not provided in community-based primary care practices."

Part of the suggested reform is to make a patient navigator an essential part of coordinated care, and more affordable for patients. Ferrante sent an application to the Agency for Healthcare Research and Quality, which falls under the U.S. Department of Health and Human Services. Ferrante's application "Increasing Preventive Services in Medical Homes Using Patient Navigation," is under review.

Ferrante has been a champion for patient navigators for some time, in all age groups and income levels, not just the geriatric population. She headed up a study in a Newark hospital from 2005 through 2007 to see the impact of patient navigation on the low-income population female population contending with suspicious mammogram results. The program, funded by the Susan G. Komen Foundation, came out with positive results for the patients. Ferrante reported, "Patient navigation is an effective strategy to improve timely diagnostic resolution, significantly decrease anxiety, and increase patient satisfaction among urban minority women with abnormal mammograms."

Schnapp also recognizes the lack of care coordination is a global problem, and not only an issue for seniors.

"Patient navigation is the center of the wheel," Schnapp said. She and Bayer refer to themselves as the "gate keepers" for their clients, to oversee the process and ensure the care inconsistencies and duplication of services do not occur.

Schnapp recommends people of all age groups keep a log listing all of their doctors, diagnoses, medications and allergies, as record-keeping and preventative measures.

A non-profit group, the Vial of Life Project, based in Marina Del Rey, California, provides "Vial of Life Kits". The group, sponsored by SeniorSafety.com, includes a form with personal information, as well as room for current and past medical conditions, medication dosage and frequency, medication allergies, doctor information, date of last hospitalization, health insurance information, emergency contact representations, and health care directives. The group also supplies decals, to be adhered to a front door. The decals alert emergency personnel to seek the Vial of Life form on the individual's refrigerator door.

Regarding prescriptions, Bubar said, "We would like to be sure we are filling all of our patient's medications, or recommend to them that they only fill their prescriptions with one pharmacy."

"When multiple specialists are involved in a patient's care it may be difficult for the primary care physician to handle this responsibility," Bayer offered. "So at a minimum I always try to suggest that all medications are filled at and purchased from the same pharmacy. In addition, I recommend that clients keep a list of all of their medications, including dosage instructions, that they provide this list to all of their physicians and health care proxies, and that they keep it in their wallet and post it in a prominent place in their homes for the benefit of first responders."

For more information about services provided by LMR Elder Care, see their website: http://www.lmreldercare.com/

To learn more about the UMDMJ study: http://www.umdnj.edu/research/publications/fall09/8.htm  

To read about Dr. Dr. Jeanne M. Ferrante's study on patient navigation with the urban minority women population: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2430139/  

To acquire a Vial of Life Kit online or by mail: http://www.vialoflife.com/ 

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