medication reconciliation in the community laying the foundation!

Marie Owen

Medication Reconciliation in the CommunityLaying the Foundation!

What is Medication Reconciliation?

• Medication Reconciliation is a formal process in which healthcare professionals partner with patients to ensure accurate and complete medication information transfer at interfaces of care

• In Home Care this involves getting information from clients and comparing it to orders, medication calendars, labels, vials and other sources of information, resolving discrepancies, communicating and documenting

Safer Healthcare Now!

• History of Medication reconciliation• What we’ve learned• Why we are proud• Why we don’t give up!

Cross Canada Check-Up

http://www.ismp-canada.org/medrec/map/

Medication Reconciliation:What it Does…

Resolves Potential Errors such as:• Failure to continue clinically important home medications while in the

hospital • Missed or duplicated doses resulting from inaccurate medication records• Failure to clearly specify which home medications should be resumed

and / or discontinued at home after hospital discharge• Duplicate therapy at discharge

What was the problem?• Clients returning home from hospital at risk for

falls, ER visits and hospital readmits due to medication adverse events

• No standardized approach to medication management

• Clients being asked for the same information by multiple care providers

• Information not shared between various care and service providers, e.g., Meds Check

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The Need• Required a standardized process for medication

management in the community• Sustainable process that generates quality data to

track changes / improvements in clients’ outcomes• Responsible for reporting to Central Local Health

Integration Network (funders of the project)• Develop a system easy to use• Internally – align with organization’s strategy to

provide quality care = safety, science, service

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What can the client/caregiver expect?

First visit:• The nurse or pharmacist completes a medication inventory

– Best Possible Medication History (BPMH)

• Makes recommendations– Preventive medicine is used and prescribed appropriately (e.g., Vitamin D, EC ASA)– Blister pack or dosette system, visual reminders– Increased PSW hours for reminders, OT assessment, referral to a community support

agency

• Summary completed identifying discrepancies and recommendations; nurse/pharmacist send letter(s) to client’s physicians• Indications are appropriately treated after feedback from physician(s)

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Example procedure of a Community Service in Ontario

What can the client/caregiver expect?

Second visit: • Education to the client/caregiver

– Administration techniques appropriate

• Provides client/caregiver with medication schedule• A copy of the medication schedule is forwarded to

the family physician and service providers

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Example procedure of a Community Service in Ontario

Examples of Limitations Identified

• Physical• Cognitive (forget to take medications)• Accessibility (cannot get to pharmacy or family physician)• Adherence (clients may refuse to take medications due to

side effects)• Safety• Knowledge gap (many clients do not understand what their

medication is, how to take it, why they require it, and what the side effects are)

• Storage and Organization

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Example procedure of a Community Service in Ontario

How have the clients/caregivers benefited?

• Enables nurse and pharmacist to:– Create a complete and accurate inventory of all medications

• Prescribed/over-the-counter/herbal• Assess for Safety, Simplicity and Correctness

– Compare the current medications with medications prescribed

– Identify any discrepancies or medication related problems• Bring it to the attention of the prescribing physician

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Example procedure of a Community Service in Ontario

Have we made a difference? • Population Health

– 1420 clients received medication reconciliation between April 2010 – March 2011

– After MMSS 43% rated ability to self-manage medications as excellent, before MMSS it was 15%

– 49% improvement in self-management

– 96% rated ability to self-manage as good or excellent

– Only 4% of clients rated fair/poor

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Example procedure of a Community Service in Ontario

Have we made a difference? • Population Health (cont’d)

– On average, 3-5 discrepancies/medication related problems identified/client

– 85% of discrepancies resolved

– 86% of medication related problems resolved

– Reduction in .5-1 medication/client

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Example procedure of a Community Service in Ontario

Interfaces in the Medication Information Transfer Process

What We’ve Learned

• It IS worth the effort - successful teams would not go back to the old way– There can still be a surprising amount of resistance– It requires new processes– It is more complicated than it sounds

• BPMH training is required

• Patient must be at the centre

• The answers are local

This Action Series

• Canada is a leading country!!

• Create more experience, successful new approaches and reliable processes in home care

• Measure success

• Learn from others and spread the learning

Question: The Problem

Do you have a sense of what the problem is? Do you believe that there is a problem in the

home care environment?

Yes? No?

A Medication Reconciliation Allegory/Metaphor!

By Mark Kearney, Pharmacist,Queensway Carleton Hospital

You come into the hospitalwearing size 32 black pants,a blue shirt,a black belt and cowboy boots…

You leave the hospital

…wearing a green dress

A blue shirt …

Red shoes

No belt

… and a cowboy hat!

Discrepancies:• Ordered a cowboy hat instead of cowboy boots

• Forgot to reorder your belt

• Got the blue shirt right

• Replaced the black pants with a red dress

Before After

What Happened?

Medication Reconciliation in Home Care

• How do we do it?• When do we do it?• Who does it?

How?

Step One

• Identify and target

Step Two• Interview• Compare• Identify• Document

Step Three

• Resolve• Identify• Communicate• Document

Step Four• Confirm• Communicate• Verify

Question

How are you Feeling?

QuestionWhat step do you feel will be the

biggest change to your current process?

Use your pointer

Does the process work? “As a nurse who is always aghast when the client hands me a shoebox full of pill

bottles, with no recourse but to just put them on the medication list, I am so thrilled to have a formal method to deal with these medications. Very often this shoebox contains every medication the client has taken for the past 10 years, many of them mixed together or missing labels.

Recently, a client was discharged on parenteral anticoagulant therapy. Without medication reconciliation, he would have continued to take the oral anticoagulant he had been on before his hospital stay. The nurse discovered this issue through the application of medication reconciliation and a potentially dangerous situation was avoided.”

Cheryl Prest RN

Can Care Health Services Pilot Team Leader

When?

Who?