Health Literacy: Elderly Pateints and Medication Review 1

HEALTH LITERACY: ELDERLY PATEINTS AND MEDICATION REVIEW 1
Health Literacy: Elderly Patients and Medication Review
Name
Institutional Affiliation
Table of Contents
Abstract............................................................................................................................................4
Chapter 1: Introduction....................................................................................................................5
Problem Statement...........................................................................................................................5
Problem Background.......................................................................................................................6
Causes of Low Health Literacy among the Elderly.........................................................................8
Cognitive Decline............................................................................................................................8
Physical Limitations........................................................................................................................9
Medication Knowledge..................................................................................................................10
Intentional Non-Adherence...........................................................................................................10
Identification of Stakeholders........................................................................................................11
Interest, Power and Influence of Stakeholders..............................................................................12
Rationale of the Practice Change and Quality Improvement........................................................13
Chapter 2: Literature Review.........................................................................................................14
Best Practices Identification..........................................................................................................19
Evidence Summary........................................................................................................................25
Chapter 3: Implementation Plan....................................................................................................28
Plan of Action................................................................................................................................28
Timeline.........................................................................................................................................29
Needed Personnel and Resources..................................................................................................30
Changes to Original Implementation Plan.....................................................................................31
Barriers Associated with Implementation.....................................................................................33

Overcoming Barriers.....................................................................................................................34
Trans-professional Relationships...................................................................................................34
How Trans-professional Relationships Facilitated Implementation..............................................35
Chapter 4: Post capstone Project Considerations..........................................................................35
Successful Aspects.........................................................................................................................36
Future Impact.................................................................................................................................36
Challenges......................................................................................................................................37
Future Impact of Challenges..........................................................................................................37
Evidence and Current Practice.......................................................................................................38
Post-Implementation......................................................................................................................39
Resource Required for Post-Implementation.................................................................................41
Chapter 5: Reflections...................................................................................................................41
Integration of MSN Program Outcomes........................................................................................41
Patient-Care Information Management.........................................................................................41
Development of Innovative Nursing Practices..............................................................................42
References......................................................................................................................................44
Abstract
Health literacy is the ability to access, understand, and use health information effectively. For
elderly patients, this is a great challenge because of declining cognitive and physical abilities. In
fact, studies show that senior citizens registered the highest incidences of medication
complications because of non-adherence to treatment instructions. Specifically, this project has
indentified inadequate communication through the medication review form as major cause of the
adverse effects associated with prescriptions. According to most frontline nurses, geriatric
patient often nod yes or provide feedback that indicates they are taking the medications properly.
However, frequent hospitalizations and transfers to nursing homes show inadequate feedback.
Accordingly, this project has developed a holistic approach to not only obtain accurate data
about medication management, but also opportunities to enhance health literacy among the older
adults. The three prolonged strategy involves a revised medication review form, drug
reconciliation guideline to reduce the number of medications, and an interactive interview for
comprehensive psychosocial data.
Chapter 1: Introduction
Health literacy refers to the ability of a patient to access, understand, and use health
information to promote wellbeing (Manafo & Wong, 2012). Therefore, being health
knowledgeable means capacity to accomplish numerous clinical processes that include selecting
insurance providers, remembering or recording names and addresses of healthcare providers,
retrieving prescriptions, monitoring use of multiple medications, and having basic knowledge of
medical terminology. In particular, elderly patients are the most affected by health literacy
deficits largely due to cognitive decline associated with advanced age. This a huge problem for
the healthcare sector because senior citizens aged 65 and older are one of the fastest growing
demographic in America, by 2030 they will comprise 20% of the population (Manafo & Wong,
2012). Studies indicated that low literacy levels among the elderly patients is directly linked to
medication errors, higher readmission rates, longer hospitalization, rising transfers to nursing
homes, and other negative health outcomes. In addition, according to the National Academy of
Aging (Manafo & Wong, 2012), almost $73 billion is wasted in resolving the problems cause by
inadequate health literacy among the aging population. This shows that enhancing elderly health
knowledge and capabilities is an important part of improving public health.
Problem Statement
To develop an effective intervention strategy required to improve health literacy among
senior citizens, identification of a particular serious deficit is necessary to show the magnitude of
the problem and establish a structure for resolving the issue. For older adults in America, the
main negative outcome associated with health illiteracy is medication complications. As Marek
and Antle (2016) points out, the number one reason, why elderly patients are transferred to
nursing homes is drug-related problems, which cost the healthcare system an estimated $14
billion annually. Due to increasing health complications during old age, senior citizens above 65
years old are the largest consumers of prescription drugs. Unfortunately, this demographic is also
vulnerable to the complexities associated with monitoring and managing chronic health issues
that require cognitive awareness. According to Marek and Antle (2016), close to 30% of elderly
patients are admitted to hospital because of adverse effects of taking medication or non-
adherence to prescription instructions. Furthermore, the report indicated that older adult patients
discharged from hospital with more than five different medications were more likely to be
readmitted, have longer hospital stays, and even die prematurely. Therefore, nursing intervention
to improve health literacy among elderly patients is crucial to alleviate this costly and deadly
problem.
Problem Background
Developing new strategies to promote health literacy among the elderly is crucial because
of the significant negative socioeconomic and health outcomes of inaction or maintaining the
status quo. According to the Medical Expenditure Panel Study (MEPS), 36% of senior citizens
have below average literacy levels, and the annual cost of this deficit is around $73-106 billion
(Manafo & Wong, 2012). Moreover, the study projected that at the current rate the future cost of
low health knowledge or capacity, in case of inaction, will rise to $1.6 trillion in 10 years. In
effect, future generations will pay a high price for a problem that can be tackled now through
developing change strategies for improving health literacy among the senior citizens.
Another major reason why a new approach to promoting medicine management skills
among older adults is needed is the availability or lack thereof of home assistance or close
relations involved in elderly care. Studies indicate that people aged 65 years and older have
decreased comprehension or are confused about medication instructions (Pearson, 2011). As

such, living arrangements have become an important factor to consider when developing a
strategy to improve health literacy for this demographic. In fact, researchers have found that
senior citizens that live alone are more likely to experience medication errors because they is no
one to monitor, remind, and assist them in adhering to their prescription regimens (Pearson,
2011). Accordingly, health educators have to take into consideration not only the learning needs
of their older adult clients living alone, but also of those with close relatives, friends, and private
caregivers.
Besides the normal cognitive decline, senior citizens also experience other health deficits
that impede learning. In particular, studies show that depression is common among older people
because of the stress of aging, abandonment, loneliness, and regular poor health consisting of
painful chronic illness such as arthritis and Parkinson disease (Pearson, 2011). Other major
mental health problems suffered by the elderly include Alzheimer’s and dementia, which greatly
affect ability to read and comprehend simple instructions. Given these mental incapacitations
that are prevalent among this demographic, new innovative methods of teaching must be
developed to improve their health literacy.
Lastly, the number of medication prescribed for numerous chronic diseases afflicting the
elderly, and the complexity of the instructions is another major reason for reviewing the health
curriculum and teaching method of senior citizens. Typically, an elderly patient is on several
drugs at the same time that can include blood pressure, diabetes, arthritis, depression, and pain
medications. According to Marek and Antle (2016), the different prescriptions and various
regimens, leads to an overdose or non-adherence, which cause adverse drug effects and
complications, and the resultant re-hospitalizations. Essentially, older adults with declining
cognitive functioning are overwhelmed by too many medications and the complexity of
following the different number of doses required for daily treatment.
Causes of Low Health Literacy among the Elderly
Cognitive Decline
Normally, education curriculum and teaching methods are designed to cater for the needs
of certain age group, thus kindergarten children as taught differently from grade school, high
school, and college students. In the same way, educating elderly patients about medication
management requires either a practice change or an innovative strategy to improve their
comprehension and compliance. In particular, the older generation as students have special needs
associated with their cognitive decline, for example, they have problems absorbing new
information compared to younger people. As Pearson (2011) explains, aging affects fluid
intelligence that is associated with reasoning or processing different components of learning.
Psychologists agree that people age differently, but senior citizens tend to demonstrate slower
cognitive processing of information and struggle to comprehend theoretical information.
Specifically, studies show that older adults have problems with comparisons, synthesizing,
computing and adapting. As a result, this means that they have difficulty with tasks that have
time constraints, require differentiation between two or more items, and have long-term
processes. Accordingly, in terms of medication management training, rushing elderly patients to
demonstrate comprehension is unadvisable because it will cause frustrations, anxiety, and
rejection of the process.
Apart from having problems absorbing new information, senior citizens also struggle
with multitasking or handling multiple messages. According to researchers, an average young
person can only recall seven different items from short-term memory, while older adults with
cognitive aging are limited to two-five objects (Pearson, 2011). For that reason, the study
concluded that elderly people absorb information in small quantities that allows them to
comprehend manageable chunks, and helps in recalling the details. Accordingly, for educators of
elderly clients, knowing how to breakdown complex topics into simple to understand
information delivered overtime is crucial, in order to compensate for short-term memory loss.
Another cognitive limitation common among older adults is problems with
comprehending abstract concepts. As Pearson (2011) points out, the aging brain slowly losses its
capacity to synthesize information and draw conclusions from deduction or reasoning. This
means that senior citizens often have difficulties with vague terms such as several times daily,
frequently, regularly and adequately. For example, change their wound bandages regularly or
several times a week is confusing and will likely lead to non-adherence. Instead, these patients
need exact instructions like two to three times weekly.
Physical Limitations
Similar to cognitive decline, the aging process causes physical limitations to body of
older adults. Senior citizens often begin to have problems with their hearing, vision, and
mobility, as they get older. Because of declining bodily abilities, elderly patients face the same
learning difficulties experiences by people with similar disabilities. For example, similar to
visually impaired individuals, aged patients have problems reading small prints labeling on
medication bottles. Often, these clients can be seen squinting, relying on touch to find their way
around or locate a keyhole, and straining to hear by turning their ear towards a speaker or fail to
answer direct questions (Mathews et al. 2012). In terms of physical functioning, decreased
dexterity, joint pains, and stiffness compromise the ability to move around or handle small
objects. Primarily, older people with arthritic problems struggle with health actions such as
picking pills from a flat surface, self-injections, reaching into high shelves, and even maintaining
personal hygiene. These physical barriers to learning require adaptive teaching strategies that
will help the elderly patient avoid medication errors through either overdose or skipping
treatment.
Medication Knowledge
Besides cognitive and physical causes, knowledge deficits about the medications
prescribed is another major reason for low health literacy among the elderly patients. One study
found that 50% of senior citizens did know the purpose or name of the medications they were
taking, and only 15% understood the side effects (Manafo & Wong, 2012). Researchers also
discovered that 64% of heart failure patients could not identify the amount/dosage and number of
times they were supposed to take their new medication. Other studies showed similar limitations
among asthma patients with inadequate knowledge on how to use inhalers and blood pressure
clients who skipped anticoagulation therapy. This indicates that there is a significant lapse in
patient education during discharge or follow-up monitoring. Chiefly, most elderly patients in one
study pointed out that medication information if often not clear and as is disorganized or
confusing when you have several prescriptions (Manafo & Wong, 2012). On the other hand,
most participants highlighted the following effective strategies for medication education, a
combination of written and oral instructions, use of pictures, and follow-up counseling through
home visits or phone calls. In effect, health literacy for senior citizens should be an ongoing
process.
Intentional Non-Adherence
A surprising cause of low health literacy among elderly patients is intentional non-
adherence due to side effects, cultural beliefs, and wrong perceptions. One study found that some
of the older adults believed that they could skip medications because their conditions were not
serious enough or the oversight could not cause complications (Mathews et al. 2012). However,
most participants indicated that the main reason for skipping does was side effects such as
headaches and diarrhea. Nevertheless, these findings highlight limitations in the patient
education or lack of critical thinking and decision-making skills. Essentially, the elderly clients
had the basic knowledge about dosages and schedules but not the capacity to synthesize and
apply deductive reasoning, which is necessary during self-management.
Identification of Stakeholders
Quality improvement in education requires the participation of various stakeholders who
play different roles in development and implementation of the project. In this case, the main
stakeholders will include the learners who are elderly patients, instructors who are the nurses,
and supervisors who include nursing educators and researchers. Other crucial stakeholders are
family members, and government policymakers and regulators. As the target of the change
improvement, the participation and contributions from the older adults will be vital for the
project. The main task of this program is to evaluate the level of understanding or comprehension
among the elderly patients who have undergone medication teaching. As Wright (2012) argues,
learning is all about the students and their level of knowledge acquisitions and comprehension.
Essentially, the main contribution of the primary stakeholder will be to provide feedback
indicating the effectiveness of the health literacy programs. The elderly stakeholders will
therefore be directly responsible for shaping the change strategy by indentifying limitations in
the current medication management program.
Another primary stakeholder is the nurse involved in development and implementation of
the course. As primary caregivers, nurses are directly involved in medication management
teaching and thus partly responsible for the outcomes. As indicated by Mathews et al. (2012),
instructors are empowered to develop their own education plan that takes into consideration past
professional experiences, learning environment, and abilities of the students. In this case, the role
of nurses is to monitor feedback and use the findings to develop a better health literacy program
for medication management among the elderly. Nurses are trained to identify problems and
develop solutions or strategies to alleviate the issues.
Alternatively, the other important stakeholders are nurse educators and researchers that
will be responsible for supervising the change process. Among their significant contributions
will include developing a change structure, coordinating resources, and implementation of the
quality improvement project. On the other hand, government policymakers and regulators have a
powerful influence on the overall program because they provide the funding, materials, and
facilities required to implement the quality improvement.
Interest, Power, and Influence of Stakeholders
The outcome of the project depends on balancing the interest, power, and influence of all
the stakeholders. For instance, the elderly patients have a high interest in their own physical
wellbeing that is adversely affected by poor medication management. In addition, since success
of the project is dependent on their health outcome, they also have significant influence on major
aspects of development. Specifically, their physical and cognitive vulnerabilities inform the
design changes of the medication review form, drug reconciliation checklist, and appraisal
interviews. However, compared to other stakeholders they have minimal power in the
implementation process that is largely run by the healthcare providers and mangers. On the other
hand, as primary stakeholders, frontline nurse have an interest in better communication with the
patients that is impeded by a poorly designed medication review checklist. As the primary
caregivers that initially noticed that older adults provide inadequate feedback, nurses have
significant power in terms of indentifying their patient’s needs, development of a better strategy
to obtain feedback, and implementation of the interview phase. Nonetheless, they have little
influence on the funding and supervision of the project.
Alternatively, secondary stakeholders include family members, who are highly interested
in the health safety of their elderly relatives and have considerable power over project
development due to personal experiences with the physical and mental limitations of the patients.
However, they have limited influence on the implementation and administrative processes. In
contrast, nurse educators are more interested in the framework of the project including how the
nurse will be trained to be better interviewers. Their power is therefore significant in project
management from the development to the implementation and evaluation stages. Nevertheless,
nurse educators have little influence in budgeting or control of strategic resources like hiring of
staff. Lastly, government policymakers and regulators are more interested in cost saving because
they have power over funding the project. On the other hand, they have little influence over
project development and implementation.
Rationale of the Practice Change and Quality Improvement
Most studies have analyzed health literacy involving senior citizens from the cause-and-
effect perspective that is, as product of aging and thus require teaching methods designed for the
elderly. Additionally, researchers have focused on the health outcomes of low or limited health
literacy that range from medication errors and frequent readmissions to higher mortality rates.
However, no substantive studies have been done on health education review or evaluation of the
effectiveness of the literacy promotion programs. In particular, most nurses have expressed
frustrations with outcomes of the medication management projects, which demonstrate enhanced
health literacy levels, but are undermined by rising cases of drug complications or adverse
effects. The typical medication reviews asks whether senior citizens know, the medication they
are taking and why, the dosage, method of intake, and the possible side effects (Manafo &
Wong, 2012). Although the checklist seems simple and the feedback is largely positive, the high
incidences of prescription non-compliance or overdoses indicate that the elderly patients are
providing false responses. In essence, the older adults often nod yes to most questions to avoid
bothering the nurses or because they did not understand the query and are embarrassed to ask for
clarification. This puzzling outcome shows that there is communication breakdown or the review
questions, presentation and process, is flawed. The purpose of this change project therefore, is to
develop an appraisal program that will produce accurate findings of the health literacy levels,
and highlight deficiencies in the patient education training.
Chapter 2: Literature Review
Numerous studies have linked education levels to health outcomes, mostly researchers
indicate that low literacy is linked to non-adherence to treatment instructions, medication errors,
adverse effects that require emergence hospitalization or readmissions, and even premature death
(Ashida et al. 2011; Berkman et al 2011; Bostock & Steptoe, 2012; Sørensen et al. 2012).
Accordingly, findings from studies conducted by the National Assessment of Adult Literacy
(NAAL), the preeminent organization that tracks education statistics in America, are crucial for
this study. Generally, the NAAL focuses on the relationship between demographics and health
literacy, for example, how age, ethnicity/race, education attainment, financial status, and access
to health insurance cover influences ability to read and understand medical information and
follow treatment instructions. In one study conducted by the NAAL, researchers found a direct
correlation between low health literacy and level of education attainment. According to findings
of the study, high school dropouts had the lowest health literacy scores followed by high school
graduates, while college educated participants were more likely to safely adhere to treatment
planning (Berkman et al 2011; Mõttus et al. 2014). In addition, the study found that poor
minorities without private insurance and advanced education make up a large number of the low
health literacy individuals. An NAAL report shows that 65% of members in this group have
difficulty reading medical instructions written using above 8th grade English (Mõttus et al. 2014).
In fact, the study indicated that a sizable number of participants in this demographic tested at the
4th to 5th grades level in a reading and writing comprehension quiz.
Similarly, a NAAL study found a relationship between age-related issues and health
literacy. According to researchers, 71% of elderly patients age 60 and over cannot read printed
material unaided, 80% have difficulty completing documents like charts and forms, and 68%
have trouble with numbers and performing calculations (Cheeser et al. 2015; Geboers et al.
2015). This study correlates to several geriatric studies that show senior citizens in America are
the most likely demographic to suffer health complications associated with non-adherence to
treatment instructions. In particular, one study by Marek and Antle (2016), found that the main
reason why elderly patients are transferred to nursing homes is frequent emergence
hospitalizations or re-hospitalizations because of adverse affects a rinsing from medication
errors.
Unlike, other age groups however, the low health literacy levels among senior citizens, is
closely linked to aging specifically cognitive and physical decline. Geriatric studies indicate that
the human brain experiences several forms of cognitive declines after the age of 65 years old. In
particular, one study found that deterioration of the frontal lobe affects fluid intelligence or
ability to process information faster and makes it difficult to synthesis abstract information
(Manafo & Wong, 2012). This means that older adults have difficulty with comparisons and
computing cognitive data or differentiating and relating health information. As a result, another
study linked non-adherence to treatment planning to frustrations and anxiety, associated with
having to deal with multiple medications, procedures such as self-injections, and self-monitoring
of vitals sings like blood pressure and heart rates (Mathews et al. 2012). In addition to mental
limitations, geriatric studies also point out that elderly people experience continuous physical
decline that significantly affects their health literacy. As researchers explain, health literacy goes
beyond ability to read medical information, an individual must also have the capacity to follow
verbal instructions, monitor their medication regimens, and plan for future consultations and
refills. Unfortunately, physical impairments like visual, hearing, and motor movement problems
among the older adults incapacitate their capabilities. One study found that 71% of senior
citizens were observed squinting during reading, 68% used touch to locate a keyhole, and almost
56% leaned towards a speaker during verbal conversations (Mathews et al. 2012). This shows
that health literacy should be tailored to fit the client’s needs in order to be effective.
Alternatively, other researchers indentified low health literacy levels among senior as a
consequence of complex medical information. Specifically, one study showed a correlation
between the number of prescriptions and the likelihood of medication complications and adverse
effects. Findings of research showed that patients with more than five different medications were
more likely to mix up dosages or forget to take some vital drugs (Marek & Antle, 2016).
Furthermore, the researchers established that almost 50% of elderly patients did not know what
some of their medications were supposed to cure (Marek & Antle, 2016). Incidentally, the study
also discovered that non-compliance was common among older adult patients who did not
recognize the seriousness of their condition or consequences of skipping drugs or certain aspects
of treatment. Essentially, their lack of personal safety concerns demonstrates inadequate
awareness of their health status.
Apart from focusing on the health literacy of patients, other studies have highlighted the
role of healthcare providers in health education and awareness. For example, Wright (2011)
established that nurses are the most effect educators because they have closer relationship with
patients than other clinicians. Similarly, another study found that patients are more likely to open
up or disclose worries and questions, to nurses with multicultural education or ethnic roots in the
community. For instance, one study involving 127 caregivers found that bilingual nurses were
more likely to report positive patient interactions than monolingual clinicians who only spoke
English (Ratanawongsa et al. 2013). However, other researchers have discovered that non-
adherence to treatment instructions is closely linked to an information gap between nurses and
their patients. In one study done among frontline nurses, data indicated that primary caregivers
were frustrated by the feedback they were getting from their elderly patients who constantly
nodded or replied yes, but later on were readmitted for non-adherence to treatment instructions
(Ostini & Kairuz, 2014). Likewise, despite recording low scores in the Functional health Literacy
in Adults (TOFHLA) tests, another study found that most senior citizens believed that they were
health literate. In the study conducted by Sorensen et al. (2012), participants were asked basic
questions about their ailments, which indicated that those who had a higher score in TOFHLA,
were more likely to differentiate between blood pressure and blood sugar levels readings.
On the other hand, other researchers focused on the literacy levels of nurses themselves.
Besides multiculturalism knowledge, studies have established that nurses with advanced
education on evidence-based health literacy education are more likely to record higher positive
patient outcomes. In one study involving women who were taking birth control, researchers
wanted to know the impact of health education from a certified nurse assistant (CAN) versus a
certified registered nurse midwife (CRM). Findings of the study indicated that participants that
had received the normal oral and written guidelines on how to use contraceptives registered
higher incidences of unplanned pregnancies than those who went through active learning
include the teach-back method (Haun et al. 2014). Furthermore, another research focused on the
impact of nurse autonomy on health literacy among patients. In the study involving pregnant
women in various clinical settings, data indicated that participants living in remote rural areas
where nurse midwives largely worked independently reported better health awareness about the
dangers of smoking and drinking, importance of balance diets, and the need for regular prenatal
and post natal care (Haun et al. 2014). On the other hand, besides recording higher number of
teen pregnancies, participants from community health centers mostly in poor neighborhoods
reported nurses who mostly took instruction from physicians, provided inadequate prenatal care.
Essentially, this study shows that nurses play an important role in not only providing primary
care but also recognizing lapses in the intervention process, which required autonomously
developed evidence-based solutions.
Alternatively, other researchers shifted from patients and clinicians to the relationship
between social support systems and health literacy. In one geriatric nursing study, data analysis
indicated that older adults with close family members or relatives that assisted them in self-care
were more likely to record positive health outcomes than those living alone. As Fransen et al
(2012) explains social support systems are crucial for enhancing health literacy because they fill
the information gaps and facilitate regular feedback and communication with healthcare
providers. For example, researchers found that geriatric patients taking multiple medications for
different illnesses such as diabetes, high blood pressure, depression, arthritis, and pain
medications, had fewer cases of complication or non-adherence if they had a person assisting
them with self-care. On the other hand, a study involving elderly patients struggling with
dementia showed that those without private help were more likely to skip their anticoagulation
therapies, have difficulty with their inhalers or self-injections, and even display sign of poor
personal hygiene (Loke et al. 2012; Manafo & Wong, 2012). In effect, these studies show that
health literacy extends to educating family members and other social support systems that are
closely related to the patient.
Lastly, some studies focused on the economic cost of low health literacy levels.
Researchers established that annually adverse effects of non-adherence to treatment instructions
cost the healthcare system $73 to $106 billion (Pearson, 2011). Most of these expenses were
used to cover the cost of emergence care, re-hospitalizations, longer hospital stays, long-term or
permanent disabilities, and premature death. Another study focused on health literacy education
as a form of preventative care that will not only save lives, but also spare the country from a
potential $1.2 trillion in health costs linked to low health literacy.
Best Practices Identification
The goal of this project is to develop a medication appraisal protocol that will highlight
literacy-related communication challenges experienced by elderly patients. To this end, the first
objective is to identify barriers that inhibit effective feedback during medication reviews largely
conducted by nurses. Among the main questions that will be explored include 1) Have the
elderly patients ever answered ‘yes’ during a prescription appraisal process without
understanding the question, 2) What type of literacy barriers are they dealing with, cognitive
decline, physical problems, or inability to understand complex medical words, and 3) What kind
of assistive technologies do they have for medication management.

Consequently, the findings are expected to correlate with results highlighted by other
researchers. According to one study of nurse-patient relationships, the main barrier to effective
clinical communication between caregivers and clients is low literacy levels (Mathews et al.
2011). Analysis of the findings indicated that almost half of the elderly patients had difficulty
with words that exceeded 8th grade English level. Because of limited schooling, most of these
patients were taking medications that they did not know or understand their effects. Therefore,
providing or developing documents that older adults with substandard education can read and
comprehend is one of the key objectives of project planning.
Another research discovered that age-related issues including cognitive and physical
limitations inhibit medication literacy. According to results from the study, senior citizens
experience loss of short-term memory, capacity to process multiple messages, and ability to
comprehend abstract concepts (Manafo & Wong, 2012). Essentially, this means that older adults
have difficulty remembering many details such as the names and regimens of different
prescriptions, and therefore require written and verbal instructions to be in simple and clear
structure that is easily readable and understandable. In terms of physical limitations, the study
highlighted poor vision as a main factor that negatively influenced medication management. In
response to this setback, the researchers pointed out several strategies to overcome vision
problems. Apart from wearing bifocals or glasses with corrective lenses, other approaches for
improving reading included medical interventions for cataracts and other degenerative issues,
additional lighting, and avoidance of certain colors that elderly people have trouble seeing like
shades of green, blue, and purple. Apart from vision problems, another common physical
disability indentified in studies is limited motor functions. Results of one study linked inability to
open medicine bottles, self-inject, and reach for drugs placed on high or low places, as a major
reason for non-adherence to medication regimens (Pearson, 2011). In response to this form of
low health literacy linked to physical limitations, adaptive technology such as scheduled
prescription alarm systems and popup containers were introduced.
Psychological considerations also play an important role in medication-management
review. For example, low self-esteem and social anxiety may explain why some geriatric patients
just nod yes to prescriptions appraisal questions, because they do not want to disturb the nurse or
be a nuisance. Even worse are mental health conditions such as depression, anxiety disorders,
and degenerative diseases like Alzheimer’s, which inhibit motivation to stay healthy or provide
self-care. As a result, researchers have come up with strategies to overcome the limitations that
include providing a clam and optimistic learning environment, including counseling in
medication training, and using repetitive teaching to overcome distortions (Marek & Antle,
2016). For instance, due to preoccupation with the many things happening in their lives including
loss of close relatives and friends, struggle to maintain personal and financial control, and
decreased concentration, medication management reviews are conducted regularly to remind
seniors the importance and possible dangers of over or under-medicating.
After indentifying the best practices in elder care education, the second objective is to
develop a formalized medication review protocol that will be used to indentify communication
barriers between nurses and elderly patients. The typical medication review checklist has three
standard questions, Do you know what kind of medication you are taking and why, and do you
know the dosage and regimens, and have you experienced any drug adverse effects. While these
questions are crucial, they are too clinical or lack patient-centered communication that is more
forthcoming and insightful. The new medication-management review protocol will therefore be
more holistic that means including open-ended and probing questions, which will allow geriatric
patients to provide personal opinions about the process. In particular, the new approach will shift
from a passive test-like approach to active learning method of obtaining information from the
older adult patients. For example, one of the strategies that will be used in the protocol will be
the “teach-back method” of medication management review. In this method, instead of providing
training on how elderly patient should develop schedules for taking their prescriptions, and then
using a checklist to gauge effectiveness, the nurses educators use the teach-back method or
show-me approach where the patient explains what they have learned. According to Manafo and
Wong (2012), the teach-back method that involves patient explaining back health details,
reinforces knowledge retention and helps instructors indentify information gaps and limitations
in the communication method. Common tips when using this approach include statement like,
“we have covered a lot of ground about (state health problem and drug treatment), and can you
explain to me when and how you are going to take the medicine?” To continuously improve the
teach-back approach, a standard guideline will be developed including progress assessment and
re-evaluation of the medical-information clarification process.
In addition to an active learning approach, the new protocol will develop a more
comprehensive medication management appraisal that focuses on deficiencies. The typical
review checklist has these questions, name all the medications you are taking, state the schedule,
or time for taking each drug, state the treatment for each drug, and indentify any complications
you have ever experienced from a prescription. While this form is sufficient for regular patients,
Manafo and Wong (2012) points out that it fails to acknowledge the numerous deficiencies of
older adults. A more active or demonstrative review document will therefore include statement
like, can you demonstrate ability to fill a glass with water or spoon with medicine syrup. Other
questions to determine physical and cognitive ability will include request to remove tops of
medical containers, ability to count pills, and demonstrations of administering medications
orally, through eye drops, inhalers, patches, and injections. All these information including
ability to successful swallow pills using water and other liquids will be recorded into the review
form. Lastly, after determining the ability to recognize and use drugs effectively, the final
inquiry will focus on long-term medication management, which includes whether the geriatric
patient knows how to refill prescriptions through clinical and pharmaceutical contacts. The
questions in this section will therefore include indentifying whom to contact for a refill, and
resource available such as a car for transportation, close relatives who can fetch your refill, and
neighborhood pharmacies and delivery services. In effect, this comprehensive appraisal form
covers all the deficiencies faced by senior patients, and thus can be used to authenticate health
literacy, which includes ability to coordinate self-care.
Alternatively, several factors that are outside the medication review document should
also be taken into consideration to prepare the interviewee and streamline the process. For
example, a medication-management reconciliation process will be part of the appraisal. Besides
looking for non-adherence and adverse effects, the medication feedback form will require
verification of inappropriate and duplicated prescriptions. According to Marek and Antle (2016),
the medication reconciliation process has three main stages verification, clarification, and
reconciliation. In the verification process, a complete audit of all medications including
prescription drugs, over the counter medications like aspirin and acetaminophen, home remedies,
herbal medicines and dietary supplements, will be collected. Then the clarification phase will
involve indentifying the names, doses, regimens/frequencies, and possible contradictions
between different medications. In effect, the goal of clarification is to highlight potentially
dangerous drug interactions or duplications (Marek & Antle, 2016). In additions, the verification
process is supposed to weed out drugs that may be harmful to senior citizens such as aspirin that
can cause bleeding ulcers. If a duplication or conflict is identified, then the nurse will consult
with the physicians and pharmacist to reconcile the prescriptions for optimal medical care.
Other significant factors linked to the medical review protocol are related to the
healthcare and social systems. Mostly of these factors focus on providing the geriatric patient
with a positive environment that will foster effective communication with caregivers. Firstly,
before administering the review form, nurses will be trained to treat the elderly patients with
respect and kindness. Among the strategies that will be used to achieve camaraderie include,
sparing a few minutes to inquire about their wellbeing and experiences in the clinical setting.
According to Mathews et al. (2011), recognizing cultural links, or acknowledging
multiculturalism is also a significant part of enriching nurse-patient relationships. Moreover, to
make the client feel relevant, the process will involve them in medication management planning,
in order to put their needs into consideration. To eliminate physical health limitations, the
protocol will develop a guideline for diagnosing vision, motor function, and psychological
problems. Consequently, elderly patients with impairments will be provided with corrective
medical equipment such as prescription glasses and hearing aids, and medication monitoring
tools like wearable alarm devices. One strategy that has been widely used to enhance health
literacy is developing reading materials that are easier to read and comprehend. As Manafo and
Wong (2012) explain, 8th grade English and large prints allows older people with sight problems
to read and understand content on medicine bottles.
Alternatively, the review form should have questions and instructions that seniors can
easily absorb synthesis and comprehend. Since this demographic has issues with complicated
medical jargon, the information should be broken into small understandable fragments that are
easy to digest. For instance, when inquiring about dosage and frequency, the questions should
not use numerical numbers like 2*3, instead, they should spell out 2 pills three times a day
(Pearson, 2011). In addition, diagrams and pictures should be used enhance communication
among the low literacy patients. Finally, the process of obtaining feedback from older adult
patients should involve family members, close friends and any other support system that ac assist
in medication management. Their viewpoint is crucial in assessment and quality improvement of
the change process.
Evidence Summary
Title: Patient Safety and Quality: An Evidence-Based Handbook for Nurses
Author: Karen Dorman Marek and Lisa Antle
Date: 2016
Key Message: Medication management strategies for community-dwelling senior citizens
Study Design: Systemic review
Evidence: Main points highlighted by this study include
1. The main reason why majority of geriatric patients are transferred to nursing homes is
medication complications caused by non-adherence to instructions, which leads to
adverse effects
2. Older adults are vulnerable to medication complications because of several factors that
include cognitive decline, physical impairments, mental disorders such as depression and
Alzheimer’s, and lack of social support system.
3. Solutions to these problems include medication reconciliation, health literacy education,
corrective equipment, and developing a support system
Title: A Nurse’s Eye-view on Health Literacy in Older Adults

Author: Lisa A. Mathews, Shine L. Alisabeth, Leanne Currie, Connie V. Chan, and David r.
Kaufman
Date: 2012
Key Message: What nurses consider being the main causes of low health literacy among elderly
patients
Study Design: semi-structured interviews
Evidence: The main points highlighted in this study include:
1. Pointed out the health literacy was linked to numerous negative health outcomes that
include frequent hospital visits, regular readmissions, transfer to nursing homes, high
healthcare cost, and premature death
2. Indentified three main barriers to health literacy, limited schooling mainly characterized
by 8th grade English level, age-related issues such as cognitive and physical decline, and
inadequate social resources including family support
3. The study proposed simpler numeracy system or presenting quantitative information such
as dosages, schedules and appointments in a clear understandable manner
Title: Health literacy Programs for Older Adults: A systemic Literature Review
Author: Elizabeth Manafo and Sharon Wong
Date: 2012
Key Message: Effectiveness of health literacy programs
Study Design: Systemic literature review
Evidence: The main points highlighted in this study are:
1. The study indentified two types of health literacy teaching methods passive and active
approaches. The passive method involves nurses lecturing elderly patients about self-care
while the active approach is more interactive by using strategies such as the teach-back
method and role-playing.
2. Also highlighted the functional health literacy approach that involves clients being
participants in curriculum development research, for example, diabetes patients are
interviewed to assess their knowledge levels
Title: Gerogogy in Patient Education-Revisited
Author: Michael Pearson
Date: 2011
Key Message: Focuses on the education limitations caused by aging
Study Design: Qualitative research
1. The study identifies the main characteristics of cognitive aging as slower information
processing, inability to manage multiple messages, and having problems with
comprehending abstract concepts
2. Physically, the researchers indentified visual, hearing, and motor impairments as
common limitation among older adults
3. Accordingly, the study recommends health literacy teaching that is designed for this
demographic including use of pictures and large words
Title: Effective Communication Skills for the Caring Nurse
Author: Ros Wright
Date: 2012
Key Message: Nurses must improve their communication skills to improve patient outcomes
Study Design: Qualitative research

1. impact of effective communication includes faster recovery rates, sense of protection and
safety, improved nurse-patient relationship, fewer medication errors and readmissions,
and better adherence to self-care instructions
2. Strategies for improving communication include enhancing verbal and nonverbal skills,
adapting active listening, developing voice control or management, and cultural
awareness
Chapter 3: Implementation Plan
The following implementation plan will highlight the measures that will be put in place to
develop a more effective medication review protocol, which include the project timeline, needed
personnel, and resources, and change theory that will guide the quality improvement. In addition,
some barriers to project execution will be underlined, and learning objectives and outcomes
explored.
Plan of Action
The action plan for project implementation will involve five major phases, selection of a
management team, identification of project goals, incorporation of the change practice,
conducting an outcome assessment, and finally develop a long-term strategy for project
maintenance. Selecting the project directors was crucial for indentifying the goal and objectives
of the project, and each team leader was eventually responsible for task accomplishment of
various components of the project. Since the aim of the project was to improve health literacy
based on patient feedback, the main objectives were to develop more informative questionnaire
for the medication review form, create an effective medication reconciliation document, and train
nurses to become better patient interviewers. Accordingly, the management team composed of
15 members was subdivide into four groups, three responsible for executing the main objectives
and one in charge of coordinating communication and task accomplishments to meet the
deadline.
Subsequently, incorporation of the change practice involved an orientation phase in
which the primary stakeholders mostly nurses and patients were informed about the
implementation process. During the actual review, the elderly patients were asked to bring a
close family member for the first comprehensive appraisal process that included 20 minutes to
complete the medication-management assessment form and a one-hour semi-structured
interview. Later on, a medication reconciliation process was conducted to authenticate findings
from the feedback. During the fourth phase of the implementation process, the nurse educators
conducted an evaluation exercise that tested validity of the feedback and improvement of health
literacy. Specifically, the assessment established that the new appraisal protocol was better at
indentifying limitations in self-care that were linked to particular lapses in the medication-
management education program. Finally, to ensure continuity of the project the new protocol
was included in geriatric nursing care policy guidelines and best practices alert system.
Timeline
The first week involved bringing together the project team that indentified the current
problem and developed a solution. Their task during this period was to conduct research on the
limitations of the medication review form, specifically why older adults provided inadequate
feedback. After obtaining this information week two, was dedicated to project planning that
focused on indentifying the goal and objectives of the project. Important activities accomplished
included discussing the scope and viability of the project, which required corroboration with
secondary stakeholders. Actual implementation of the project occurred in week three starting
with orientation, and sending the elderly patients a copy of the new medication review form and
instructions for the interview. More nurses were required for the new comprehensive protocol
that required more time to complete. In week four, outcome of the project was assessed by
measuring feedback against adverse effects caused by medication and evaluation of health
literacy levels. Finally, in week five, the new protocol was established as an evidence-based
practice through policy implementation.
Needed Personnel and Resources
The human, financial, and material resources required for this project include clinical
directors, sources of funding, and a communication strategy to monitor and supervise progress.
The human resource will largely compose of frontline nurse, nurse educators, and physicians.
The primary care nurse will have to undergo training on active or interactive learning, which
essentially retrieves feedback while promoting health literacy. According to Leong and Clutter
(2015), active teaching requires the instructor to implement student-focused learning that
promotes critical thinking and decision-making skills. Alternatively, the role of nurse educators
will be to supervise the quality improvement, while doctors will review medication
reconciliation that requires compiling a list of all the medications, supplements, herbals,
vaccines, and over-the-counter drugs, a patient is currently using.
Another crucial resource required for this project is adequate financing that will fund
material and wage expenses. Most of the funding will come from internal sources mainly the
hospital’s budget and contributions made by the Los Angeles department of public health. On the
other hand, additional financial support will be sourced from research donors such as the
American Nurses Foundation (ANF), and National Institute of Nursing Research (NINR).
Alternatively, implementation of the new protocols will require significant material
resources including communication networking systems, national health literacy databases,
cognitive testing guidelines, and support from professional organizations. In particular, the new
medication review protocol will involve constant communication between nurses and patients,
family members, doctors, pharmacists and other stakeholders, which requires an efficient digital
communication system that operates in real time. Likewise, access to a health literacy databases
such as the National Assessment of Adult Literacy (NAAL) is crucial because the organization
provides invaluable insights into the relationship between social variables and health knowledge
and provides guidelines to the development of health document of information that is tailored to
address deficiencies (Cutilli & Benette, 2011). Since the new protocol is specifically designed
for older adults with progressive cognitive declines, testing resources developed by the American
Medical association (AMA) such as the test of functional health literacy (TOFHL) will also be
vital for evaluating the feedback information. Lastly, professional organizations such as
American Association Colleges of Nursing (AACN), Professional Nurse Educators Group
(PNEG), and Association for Nursing Professional Development (ANPD) will provide guidance
on evidence-based quality improvement as part of nursing practice. On the other hand,
organizations like the National Gerontological Nursing Association (NGNA) and Coalition of
Geriatric Nursing Organizations (CGNO) will provide significant information of health
management of older adults including how to communicate with them effectively.
Proposed Change Theory
The Lewin’s change model will be used to guide implementation of this project. This
model has three main steps unfreeze, change and refreezes stages. Essentially, in the unfreeze
stage the status quo or current way of practicing is dismantled, the change stage ushers in the
quality improvement, and finally the innovation is entrenched into the system through policy
guidelines. In this case, the unfreeze phase will take place during the development phase of the
project. According to Rack, Dudjak and Wolf (2011), the first step in the Lewin’s change model
is to identify the focus of change or problem. The main problem indentified is false feedback
from older adult patients that leads to complications, re-hospitalizations, and even premature
death. During the unfreeze process therefore, a new comprehensive medication review protocol
will be used to establish capacity for self-care and health literacy levels. Resistance is often
common during the unfreeze phase, so regular discussions and workshops will be conducted
between primary stakeholder at the clinical setting to indentify and overcome barriers.
Consequently, the change phase or moving stage will involve the actual implementation
of the new medication review protocol. The execution process will require effort from each
stakeholder, nurses educators will provide the revised prescription drugs appraisal form, doctors
will conduct the medication reconciliation to eliminate unnecessary and conflicting drugs, and
nurses will perform the actual patient interviews. Apart from active involvement of all personnel,
this phase also requires proper management of time, financial and material resources. Lastly,
after evaluating the outcome, the new protocol will be refreezed by providing ongoing long-term
support such as entrenchment in policy guidelines and best practices alert.
Changes from Original Implementation Plan
Originally, the plan was to consolidate several medication review forms into one
comprehensive checklist. Some of these forms include the Medication Therapy Management
(MTM) mostly used by doctors, Medication Action Plan (MAP) used for treatment planning, and
Personal Medication List (PML) that indentifies all the prescriptions. Combining these three
appraisal forms into one that is patient-focused was intended to highlight major deficiencies,
which explain non-adherence to drug regimens. However, analysis of the ineffective medication
management feedback indicated that communication with senior citizens requires more
interactions and continuous health literacy teaching because of their declining cognitive and
physical abilities. As a result, some to the information contained in the MTM, MAP, and PML
was converted into semi-structured interviews as part of the medication review protocol. Unlike
checklists, oral interactions are more relatable and can be used as teaching experiences. For
example, instead of the doctor just monitoring the prescriptions provided to individual patients,
the nurse can actually find out how well the self-care process is going including incidences such
as skipping dosages, usage of herbals supplements and other alternative cures, possible side
effects, and availability of family support. In essence, the active or direct communication
approach is more effective and informative, which is crucial for indentifying change factors
needed for future quality improvements.
Barriers Associated with Implementation
Although the project was successfully implemented, two major barriers had to be
overcome during the training and administration stages. Firstly, nurse training was a crucial
aspect of this program because they are directly involved in verbal feedback compilation process,
which are supposed to collect medication management data. However, during implementation it
was discovered that the scope of learning was wider than expected, instead of just teaching
nurses to follow a simple checklist, the training process required advanced skills such as
knowledge of geriatric counseling and being bilingual. In terms of administrative barriers, the
project experienced resistance from nurses who thought the process required a lot of extra effort
that added to their workload. As Cowin (2013) points out, worries about excessive workloads is
one of the main causes of resistance to quality improvement processes. In addition, some of the
senior staff mostly doctors and pharmacists did not seem enthusiastic when transferring some of
the responsibility to nurses. They were worried about nurse autonomy and possibility of losing
more authority in future.
Overcoming Barriers
Although the medication review protocol is not really a literacy program, aspects of
health education have been included through the active learning process. For example, the teach-
back method has expanded into health literacy teaching. To overcome this problem, the project
emphasized the difference between medication appraisal training and patient education that can
be conducted as part of advanced nurse education. In essence, the four-month course was
designed to gather information and therefore if the senior citizens required further knowledge,
the nurse was instructed to direct them to health instructors or doctors who were responsible for
comprehensive medication management training. Alternatively, the issue of language barrier was
tackled through hiring interpreters and more local or bilingual nurses. As Herceg (2015)
explains, effective communication is a key aspect of smooth transition during a change process.
Similarly, to overcome the problem of staff resistance due to excess workload, more nurses were
hired and tasks redistributed to provide sufficient time and effort for medication appraisals. In
terms of resistance from higher authority, efficient communication channels such as digital
verification documents were used to ensure that physicians and pharmacists confirmed and used
the data obtained from patient feedback.
Trans-professional Relationships
According to Ells et al. (2011), healthcare has changed from a vertically organized
clinical setting that compartmentalizes professional responsibilities, to a horizontally integrated
system composed of multidisciplinary teams of clinicians and nonmedical stakeholders.

Likewise, this projected has exploited the expertise of a multidisciplinary team of trans-
professionals to achieve its goal of developing and effective feedback process that will improve
medication management. These project stakeholders include nurses, nurse educators, physicians,
administrators, and professional organizations.
How Trans-professional Relationships Facilitated Implementation
Each stakeholder played a significant role in development and implementation of the
project. Specifically, as primary caregivers, nurses were the target of the change process that
included training them to conduct more effective medication review interviews. Apart from
administering the appraisal form, the nurses obtained actionable feedback from the older adult
patients through active or interactive conversations. Alternatively, the nurse educators who are
responsible for developing health education curriculum provided valuable information about
active learning strategies such as teach-back approach and role-playing. In effect, their
supervisory role was responsible for quality improvement at the development stage of the
project. Similarly, physicians as frontline stakeholders played a major role in development of a
more comprehensive medication review form and implementation of prescription reconciliation
guidelines. Moreover, they were instrumental in shifting responsibility and authority to conduct
medication history assessment to nurses. Lastly, administrators and professional organizations
such as National Assessment of Adult Literacy (NAAL) and Geriatric Nursing Organizations
(CGNO), provided insight into the aging mind of senior citizens and ways to promote and
improve health literacy for this demographic. In particular, these organizations highlighted
efficient ways to educate elderly patients that are experiencing progressive cognitive and
physical decline due to aging.
Chapter 4: Post Capstone Project Considerations

Successful Aspects
The overall success of this project is highlighting the importance of effective
communication tools in a clinical setting. As demonstrated in the project, even a simple
medication review form can be the difference between, effective home care and frequent
hospitalizations, assisted living and being confined to a nursing home, or even life and death.
Specifically, unlike the previous medication review checklist that focused on the what, why and
side effects of drugs, the new comprehensive treatment protocol highlights more self-care
information including abilities to orally, inject, or inhale medication, and capacity to make
follow-up consultations and seek drug refills at local pharmacies. Furthermore, the quality
improvement has allowed geriatric nurses to indentify social support systems like close family
members that can assist in elderly home care. Similarly, unlike the previous inadequate program
that allowed self-conscious older adults to get away with nodding yes to all questions to avoid
being irritants, the new protocol goes beyond the passive inquiries to active interactions, which
encourages the clients to be more forthcoming. Besides improving the outcomes of geriatric
patients, the new protocol has increased awareness of the literacy needs of older adults, which
include slower and simple communication, use of assistive technology such as reading glasses
and brighter colors, and regular active instruction through methods like the teach-back approach.
In addition, the project has not only enhanced communication between stakeholders but also
promoted the importance of evidence-based practice derived from frontline nursing and patient-
focused care.
Future Impact
One of the crucial aspects of this project, which will be valuable for future quality
improvement, is the holistic intervention strategy that shifted from a mere checklist to a three-
way approach for obtaining quality feedback from patients. In essence, the holistic approach has
encompassed the psychological, physical, and social needs of the patients. As a results, the
practice changes helped older adults become more forthcoming by creating a more
comprehensive medication review form, training nurses to conduct better appraisal interviews,
and by including a prescriptions reconciliation guideline. This holistic approach, will definitely
promote future evidence-based care such as including patients and family members in treatment
planning, use of unconventional approaches such as music therapy to alleviate stress and pain,
and analysis of socio-cultural factors as part of diagnosis.
Challenges
Although the project improved interdisciplinary corroboration, nurses continue to
struggle with autonomy and workload challenges. Medication review was previously a task
conducted by the doctor who would regularly delegate the task to frontline nurses. Therefore,
transferring complete authority of this new drug appraisal protocol to nurses has not completely
overcome the resistance, which affects ability to operate optimally. Likewise, although the
nurses have been assured of bringing in more staff to assist with the workload, most are still
complaining that this new medication review and literacy supervision task, is considered extra
duty in their already congested to-do-list. In effect, nurses lack independence to conduct
effective medication reviews and are also dealing with excess workloads.
Future Impact of Challenges
If promises to address these challenges are not fulfilled, the future prospects for quality
improvement are definitely dismal. In particular, failure to monitor the medication of senior
citizens due to overwork of lack of job satisfaction will increase the chances of medication errors
and cost of healthcare, which will in turn negatively affect future funding of clinical innovations.
Similarly, antagonizing frontline caregivers will increase resistance to other potential innovations
like life saving technologies that include medication barcode devices used to monitors dosages.
Furthermore, bedside nurse who lack autonomy will be less likely to pursue innovative clinical
strategies such as patient-centered care or allowing patient to play a role in their own treatment
planning or decision-making.
Evidence and Current Practice
This project was initiated to eliminate the difference between practice and evidence,
which in this case was reviews or feedback that indicated effective medication management
among older patients, but often resulted in negative outcomes from adverse drug effects. In
particular, nurses discovered that elderly patients often nodded yes or shrugged to show
compliance with treatment instructions, but later on most of them ended up in emergence
hospitalization, readmission after a recent discharge, or had to be transferred to nursing homes
because of non-adherence to medication regimens. In effect, the difference between feedback
and outcome indicated evidence of ineffective communication between primary caregivers and
the geriatric patients. A further analysis of the evidence indicated lapses in written and oral
communication, essentially, the medication review forms were insufficiently composed and the
verbal interactions between nurses and older adults was inadequately passive. This means that
most senior citizens ignored the feedback checklist because of cognitive and physical impairment
or because they did not want to be a nuisance. According to Shever and Titler (2012), the
cognitive and physical declines that comes with aging including inability to see, hear and move
properly, and difficulty with reasoning and making decisions, are the main reasons for low health
literacy levels among people 65 years and older. Incidentally, this demographic is also the most
medicated and fastest growing age group, which highlights the enormity of the problem. As
Manafo and Wong (2012) points out, the US healthcare system is already spending more than
$73 billion annually for treatment of adverse effects linked to medication non-adherence.
In response to the ineffectual communication tools and method, this project has
implemented a holistic medication appraisal process that includes a reviewed medication
management form, improved prescription reconciliation, and active or interactive assessment
interviews. Significant changes brought on by the quality improvement include a shift towards
patient-centered care that is focused on the capabilities, attitudes or opinions, and social
background of elderly patients. Moreover, the change practice has enhanced corroboration
between stakeholders, for instance, nurses conduct the medication reconciliation that is verified
by pharmacist and the information used by doctors to develop or reevaluate a treatment plan.
Coincidentally, given the rapid changes in medical technology especially the introduction of
monitoring technologies such as medication barcodes and wearable heart and blood pressure
monitors, the fundamentals of this change practice will be the basis for remote monitoring of
older adults living at home. Studies indicate that the effectiveness of telemedicine is dependent
timely and accurate data collection and evaluation (Broderick & Lindeman, 2013). This shows
that in future remote monitoring will require the same comprehensive review process highlighted
in this project.
Post-Implementation
Monitoring medication management among geriatric patients is a long-term process. As a
result, the project will require short-term and long-term strategies to ensure maintenance and
sustenance of the new appraisal protocol. As indicated, an important aspect of short-term
continuation of the program is preventing excessive workload that comes with more nurse
involvement in the review process. Nurses will not only be required to participate in
development of medication review question, a major part of the new holistic process is training
them to conduct interactive and educative appraisal interviews. For example, using the teach-
back method, they will regularly ask older adult patients to recount the dosages and medication
regimens. This labor-intensive task included in the daily nursing duties can lead to job stress,
high employee turnover, inadequate care, and further negligence. As result, post-implementation
plans will include plans to hire more nurses or redistribute the workload to ensure that geriatric
nurses focus on the preventative care initiative.
Also highlighted earlier is the possibility of power struggles between nurses and higher
authority mainly physicians and pharmacies, during the implementation process. Most clinical
settings are used to the traditional top-down management structure where doctors and
management control the actions of subordinates like frontline nurses (Kieft et al. 2014).
Therefore, to prevent ego clashes, a short-term transitional strategy will include awareness
sessions or workshops to promote the benefits of horizontal management of shared
responsibilities, which include reduced workload for doctors and better decision-making from
teamwork and group discussions. Autonomous practice by nurses is crucial for effective
implementation of the new medication review protocol because their relationship with the elderly
patients is the basis of the project.
Alternatively, in terms of long-term sustenance plans, the new procedures developed for
obtaining feedback from older adults should be included in medication management guidelines.
Since the new comprehensive protocol will be replacing the older drug appraisal checklist such
Medication Therapy Management (MTM) mostly used by doctors, Medication Action Plan
(MAP) used for treatment planning, and Personal Medication List (PML), policy procedures
should be changed to correspond with this new process. The policy changes should include
standardization of questions in the revised medication review form and development of a more
efficient medication reconciliation procedure. Changing the structure of the medication review
process will promote future quality improvements to use the current system as benchmark.
Resource Required for Post-Implementation
As noted, the most important post-implementation goals are to hire more nurses to avoid
excess workload, develop a horizontal or teamwork power structure, and establish the new
medication review protocol as the basis for future quality improvement. Accordingly, the
resourced needed to accomplish these objectives will include budget revision to increase funds
for hiring and training new frontline nurses. Alternatively, to change the chain of command in
the clinical setting a series of multidisciplinary meetings will be required to set up the new
corroborative decision-making framework. Lastly, entrenchment of the new protocol will involve
the authority and policy formulation of professional and government agencies such as the
American Nursing association (AMA) and National Assessment of Adult Literacy (NAAL).
These organizations will include the protocol in the evidence-based best practices healthcare
guideline or clinical operations handbook.
Chapter 5: Reflections
Integration of MSN Program Outcomes
Quality improvement of the medication review protocol relied on patient-care
information improvement and management strategies, and innovative design from best practices
in nursing. Integration of these two MSN course outcomes into the project followed different
approaches.
Patient-Care Information Management

According to Staggers et al. (2012), information management in healthcare is crucial
because all clinical operations are dependent on the interactions between stakeholder in the
medical sector including patients, nurses, doctors, nurse leaders, administrators, and public
health agencies. For that reason, this project has borrowed lessons on how to develop an
effective communication strategy by focusing on three main factors of information transfer, the
message, channel, and receiver. In this case, the message is the medication management
feedback, channel is the revised medication review form, and the receiver is the elderly patient.
Since this demographic has unique health needs, the project has integrated information
management approaches that fit in with the age group. These methods include use of simple clear
and precise language in the medication appraisal form, and shifting from passive review
questions to the more interactive teach-back approach that encourages the receivers (senior
citizens) to be more forthcoming. In essence, the protocol has adapted a holistic approach to
improving information management by revising the message to make it suitable for the target
audience, developing a better channel through nurse training, and by making the making the
receiver part of the two-way conversation.
Development of Innovative Nursing Practices
Another MSN outcome that was integrated into this project was design strategies for an
innovative evidence-based practice that improved patient care. As Stevens (2013) points out,
designing a new intervention approach requires extensive research of the missing link between
practice and evidence. In this case, the project research started out by evaluating health literacy
in a particular age group. Findings of the study indicated that despite significant progress in
geriatric nursing, this demographic continued to register negative health outcomes in areas such
as medication management and communication with healthcare providers. As a result, elderly

patients are more likely to experience adverse effects of drugs due to non-adherence to treatment
instructions (Stevens, 2013). Indentifying evidence of structural failure in the communication
management system thus created a goal for the project. In essence, project design focused on
developing a new medication review protocol with a holistic perspective. The subsequent project
design framework was developed to achieve the objective of accessing quality feedback. This
blueprint included a three prolonged approach to improving the relationship between nurses and
elderly patients. In effect, the project design assisted in highlighting a major lapse in nursing
practice, and thereafter developing an effective patient-centered solution.
In brief, the comprehensive medication review project was aimed at improving the
quality of feedback obtained from geriatric patients. During project development, the current
prescriptions review checklist was identified as the weak link in medication management. In
particular, frontline nurse recognized that older adult patients registered high adherence to
treatment instructions, but always ended up in emergency hospitalization and readmissions,
which often forced relatives to transfer them to nursing homes. The new holistic protocol that
includes a revised medication review form, medication compliance, more interaction between
nurse and patient, therefore is an answer to this problem that is a huge financial burden and great
threat to the quality of life of senior citizens.

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Health Literacy: Elderly Pateints and Medication Review 1

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HEALTH LITERACY: ELDERLY PATEINTS AND MEDICATION REVIEW 1

Health Literacy: Elderly Patients and Medication Review

Causes of Low Health Literacy among the Elderly.........................................................................8

Interest, Power and Influence of Stakeholders..............................................................................12

Rationale of the Practice Change and Quality Improvement........................................................13

Chapter 2: Literature Review.........................................................................................................14

Best Practices Identification..........................................................................................................19

Chapter 3: Implementation Plan....................................................................................................28

Needed Personnel and Resources..................................................................................................30

Changes to Original Implementation Plan.....................................................................................31

Barriers Associated with Implementation.....................................................................................33

How Trans-professional Relationships Facilitated Implementation..............................................35

Chapter 4: Post capstone Project Considerations..........................................................................35

Future Impact of Challenges..........................................................................................................37

Evidence and Current Practice.......................................................................................................38

Resource Required for Post-Implementation.................................................................................41

Integration of MSN Program Outcomes........................................................................................41

Patient-Care Information Management.........................................................................................41

Development of Innovative Nursing Practices..............................................................................42

insurance providers, remembering or recording names and addresses of healthcare providers,

knowledge and capabilities is an important part of improving public health.

To develop an effective intervention strategy required to improve health literacy among

decreased comprehension or are confused about medication instructions (Pearson, 2011). As

developed to improve their health literacy.

following the different number of doses required for daily treatment.

Causes of Low Health Literacy among the Elderly

management requires either a practice change or an innovative strategy to improve their

intelligence that is associated with reasoning or processing different components of learning.

cognitive processing of information and struggle to comprehend theoretical information.

processes. Accordingly, in terms of medication management training, rushing elderly patients to

demonstrate comprehension is unadvisable because it will cause frustrations, anxiety, and

rejection of the process.

with multitasking or handling multiple messages. According to researchers, an average young

Another cognitive limitation common among older adults is problems with

need exact instructions like two to three times weekly.

apply deductive reasoning, which is necessary during self-management.

Quality improvement in education requires the participation of various stakeholders who

the current medication management program.

Another primary stakeholder is the nurse involved in development and implementation of

develop solutions or strategies to alleviate the issues.

facilities required to implement the quality improvement.

Interest, Power, and Influence of Stakeholders

influence on the funding and supervision of the project.

project development and implementation.

Rationale of the Practice Change and Quality Improvement

and highlight deficiencies in the patient education training.

Chapter 2: Literature Review

4th to 5th grades level in a reading and writing comprehension quiz.

hospitalizations or re-hospitalizations because of adverse affects a rinsing from medication

consequence of complex medical information. Specifically, one study showed a correlation

of treatment. Essentially, their lack of personal safety concerns demonstrates inadequate

awareness of their health status.

developed evidence-based solutions.

closely related to the patient.

Researchers established that annually adverse effects of non-adherence to treatment instructions

potential $1.2 trillion in health costs linked to low health literacy.

Best Practices Identification

of assistive technologies do they have for medication management.

comprehend is one of the key objectives of project planning.

prescription alarm systems and popup containers were introduced.

Psychological considerations also play an important role in medication-management

include providing a clam and optimistic learning environment, including counseling in

decreased concentration, medication management reviews are conducted regularly to remind