GRAM® Research Project
Pharmacist Technology for Nursing Home Safety

The Geriatric Risk Assessment MedGuide software (GRAM®) is being studied in a three-year research project funded by the Agency for Health Care Research and Quality (AHRQ), U.S. Department of Health and Human Services. The study focuses on pharmacists’ impact to improve patient safety by reducing serious, preventable adverse drug events (ADEs)—including delirium and falls, two of the most common ADEs in nursing facilities—through the use of the GRAM® software.

The Center for Gerontology and Health Care Research at Brown University is the principal investigator with the ASCP Foundation as co-investigator. Twenty-six nursing facilities serviced by Beeber Pharmacy of Englewood, Ohio and Home Care Pharmacy of Cincinnati, Ohio, serve as the study sites.

Rationale for the Research Project
The rationale for this project is based on research in nursing facilities, which indicate that the average resident uses multiple medications, experiences changes in the way medications are used by the body, and suffers from multiple co-morbid conditions, all making older persons more vulnerable to adverse medication effects. A study published in 2000 of residents in 18 Massachusetts nursing facilities estimated 1.89 ADEs per 100 resident-months, of which half were deemed preventable. Of preventable ADEs, 70% occurred at the monitoring stage of the medication use process.

The GRAM® software uses information technology to facilitate informed, shared decision-making and monitoring for medication-related problems. The GRAM® software links directly into the Resident Assessment process and the problem identification process pathway. The underlying theory of the Resident Assessment process is that individualized resident care will improve resident safety and well-being. The GRAM® software is a tool for use in this process and is most valuable when incorporated into the pharmaceutical care process and the resident care plan. The software assists pharmacists identify potential relationships between a resident’s medication regimen and the resident’s physical, functional, and psychosocial status and incorporate the assessment language into their recommendations. For these recommendations for medication monitoring to have a real impact, they must be incorporated into the care plan.

Experimental Design and Data Collection
The 26 nursing facilities recruited to participate in the study were randomized to receive the GRAM® software intervention or usual care. The types of data required for the project include MDS data, pharmacy claims data, and cost data. Primary data will also be collected for the outcome evaluation through chart abstraction and review. In addition, staff from the nursing facilities and pharmacy were surveyed regarding the impact of GRAM® on factors such as efficiency, productivity, workload, and job satisfaction. A process evaluation was also conducted to better understand the role of consultant pharmacists in preventing adverse drug events in the long-term care setting. This evaluation will include the determination of the extent of the "dose" of the intervention received and "process" outcomes, including the success of getting recommendations into the care plan.

The GRAM® Intervention
The intervention evaluated in this study involves specific activities of the pharmacy, the consultant pharmacists, and the nursing facilities for newly admitted residents, residents who have triggered the falls and/or delirium RAP, and those residents undergoing an annual assessment. The pharmacies’ intervention steps include generation of GRAM® RAP-Med Reports for all new admissions and those undergoing an annual assessment in the intervention facilities and appropriate medication monitoring recommendations for falls and/or delirium. The pharmacy will also request from the intervention facilities a list of patients who have triggered the falls and/or delirium RAP since the last consultant pharmacist visit and will generate GRAM® RAP-Med Reports, which will be given to the consultant pharmacist prior to his/her visit to the facility.

The ASCP Foundation trained the intervention pharmacists on the purpose, use, and methodology for development of the GRAM® software; the federally mandated resident assessment and care planning process, including the MDS, RAPs, and utilization guidelines, with special emphasis on delirium and falls; medications that may cause, aggravate, or contribute to falls and delirium; and the appropriate format for writing recommendations for inclusion in the care plan. Participating consultant pharmacists also attended the ASCP Foundation’s Disease Pharmacotherapy Traineeship. A communication plan for transmission of recommendations to prescribers and nursing facility staff was developed and implemented. In addition, an orientation program for prescribers and nursing facility staff was conducted to introduce the purpose of the study, the GRAM® software, and report content and format, and to determine an appropriate communication plan.