Continuity of CareComponents of a Meaningful Primary Care Visit

Pre-Visit Visit Post-Visit Inter-Visit

Review notes – your last note, any notes by other MDs in the interim, ER or discharge summaries

Inform patient of their PCP and nurse – provide resources (business card and team photo composite)

Assign PCP in EMR Complete timely DC summary including the PCP name and H & P.

Review interim labs Review all meds (purpose, frequency, dose, other) with patient and give them a copy of the updated med list

Document diagnostic tests and studies ordered and pending (IP) and follow up on them

If patients’ meds change when admitted based on MUSC’s Automatic Therapeutic Substitution, change them back to patient’s insurance formulary at the time of discharge

Review interim studies – ex. mammogram, stress test, colonoscopy, etc.

Give the patient a medication bag and encourage taking it with them to all provider visits

Notify UIM PCP when seeing another provider’s patient by using the “.cc code.” (OP)

Visit or call the patient during hospitalization when notified of their admission

Review any consults Look up provider codes in EMR through knowledge base.

Set up any needed health maintenance

Notify patient of test results

Continuity of CarePatients 65 years and older have multiple medical problems, are

on multiple medications, and are seen by multiple providers. Having a primary care physician, communicating among all providers, and

reconciling medications are all essential for quality patient care.

Ask the patient…

1. What are the names of the medications (including OTC, vitamins, herbal supplements and eye drops) you are currently taking?

2. How do you take your medications and how much have you been taking?

3. Do you understand what the medication is for?

4. Where do you get your prescriptions filled?

MD action…

1. Compare home list to the list in the patient’s chart.

2. Ensure dose and frequency are the same and there is a clear indication for every medication.

3. If patient doesn’t understand what meds are for, educate using plain, non-medical language; speak slowly; break down information into short statements.

4. Call the pharmacy if there is any discrepancy between the patients’ reported meds and your list. Rectify in the patient’s chart.

Medication Reconciliation Steps

References: Wenger, N.S. and R.T. Young (2007) “Quality Indicators for Continuity and Coordination of Care in Vulnerable Elders.” JAGS 55:S285-292.Varkey, P. et al (2007) “Improving Medication Reconciliation in the Outpatient Setting.” Jt. Comm J on Quality & Patient Safety 33:5.

Funding provided by D.W. Reynolds Foundation

Obtain medication list from patient

Obtain medical record medication and

problem list

Identify discrepancies

Include updated list in clinic note

Give patient a copy of updated

medication list

Document updatedmedication list

Optimize the list

Reconcile list

Call pharmacy or call family

Consolidate meds

Incorporate into med list

Enumerate all meds

Evaluate ongoing need of each med.