transitions in care: optimizing medication reconciliation ryan centafont, pharmd clinical pharmacist...

Transitions in Care: Optimizing Medication

Reconciliation

Ryan Centafont, PharmDClinical Pharmacist

Doylestown HospitalOctober 29, 2015

Review key terms relating to medication reconciliation.

Appreciate the importance of medication reconciliation in transitions of care.

Understand the barriers and solutions to successful medication reconciliation.

Recall the approach to conducting an effective patient interview.

Review strategies for optimizing medication reconciliation at admission, transfer, and discharge from a hospital.

Understand the need for pharmacist clinical interventions at transitions in care with Doylestown hospital as a case example.

Introduction

Why Medication Reconciliation Matters

Medication Reconciliationat Doylestown Hospital

Barriers to MedicationReconciliation

OptimizingMedication Reconciliation

AgendaObjectives

Question

Which of the following are barriers to successful medication reconciliation?

A) Low health literacy of a patient or caregiverB) Well-defined roles in medication reconciliation

process among staff membersC) Lack of “buy in” of Providers in medication

reconciliation processD) A and CE) All of the above

What is a “Transition in Care?”

Transition in Care - The movement of patients from one health care practitioner or setting to another as their condition and care needs change

• Within Settings• Between Settings• Across Health States

Medication Reconciliation

• The process of identifying the most accurate list of all medications that a patient is taking and comparing it to an existing and/or previous medication regimen.

Why is this so Difficult?

Home Care

Long Term Care facility

Hospice Care

Primary Care Physician

Specialist

Community Pharmacy

Hospital

Urgent Care Center

Patient/Caregiver

Goal of Medication Reconciliation

• Improve patient well-being through education, empowerment, and active involvement in the accurate transfer of medication information across the health care continuum.

What’s at Stake?

Patient Safety

Approximately half of all hospital-related medication errors and 20 % of ADEs have been attributed to poor communication at the interfaces of care.1

Patient Satisfaction (HCAHPS)• Communication

about medications• Patient perceptions

Joint Commission Accreditation

2011 – Incorporated into National Patient Safety Goal #3

Readmissions• Confusion at

discharge & poor adherence

Meaningful Use

Requirements• Electronic collection

and sharing• Incentive payments

1. Barnsteiner JH, et al. Medication Reconciliation: transfer of medication information across settings: keeping it free from error. J Infus Nurs. 2005;28(2 suppl):31-6

Medication Reconciliation – Foundation of Pharmaceutical Care

Medication Reconciliation

Patient Safety

Clinical Quality

Patient Satisfaction

MTM

Measurement

Outcomes Across Care Settings

• ObjectiveUnderstand the

barriers and solutions to successful medication reconciliation

Introduction





Agenda

Barriers to Successful Medication Reconciliation

Patient Barriers

Provider Barriers

System Barriers

Patient Factors

• Limited knowledge of medications• Low health literacy• Cognitive impairment• Not keeping an updated medication list

Integration of Health Information Technology

Interdisciplinary collaboration and information sharing

Standardization of patient interview process

Provider Barriers

• Limited time, competing demands• Lack of “buy in”• Ambiguity regarding ownership of outpatient

medications• Multiple providers and specialists involved in

care

Culture of Accountability

Collaborative, interdisciplinary approach


System Factors• Unclear roles and expectations• Insufficient staffing• Poorly designed electronic tools that do not provide user-

friendly documentation of medications• Failure to integrate processes into providers’ workflow• Multiple (often conflicting) sources of medication• Lack of integration among electronic health records

Collaborative, Interdisciplinary approach


Coordinated Communication

Standardization


Keys to Overcoming Barriers to Medication Reconciliation

Patient-CenteredMedication Reconciliation

QualityImprovement

InterdisciplinaryApproach


CoordinatedCommunication

Standardization

Integration ofHIT

• Objectives Recall the approach to conducting an effective patient

interview

Review strategies for optimizing medication reconciliation at admission, transfer, and discharge from a hospital

Introduction





Agenda

Historical “Truth”

• How do we know George Washington crossed the Delaware river in 1776?

Primary Sources – diaries, newspapers, government documents

Secondary Sources – history books

Compiling the “True” Medication History

• Utilize Primary Sources to the fullest (patients/caregivers)

• Complement primary sources with secondary sources of information– Medication lists from Primary Care Physician or

specialists– Pharmacy fill history– Third party prescription claims data– Prior History and Physical reports– Prior discharge summaries– Other healthcare facility documentation

Home

Healthcare Facility

Home

Admission Reconciliation

Discharge Reconciliation

Medications ordered and internal transfers

Admission Reconciliation Facts:

Errors in medication histories are the most common source of discrepancies, affecting up to two-thirds of admitted patients.2

More than 25% of hospital prescribing errors can be attributed to incomplete medications histories at time of admission.3

2. Tam VC, et al. Frequency, type and clinical importance of medication history errors at admission to hospita: a systematic review. CMAJ 2005; 173:510-515.

3. Dobranski S. et al. The Nature of Hospital Prescribing Errors. Br J Clin Goverance 2002; 7:187-193

Key Players in Admission Reconciliation:

Patient/Caregiver

Pharmacy personnel

Nurses

Providers

Obtaining the Best Possible Medication History (BPMH) – A Systematic Approach

STEP 1: Pre-Interview preparation - obtain information on the patient’s past medical history and past medication regimens. Begin correlating past diagnoses to treatments. Leverage information systems.

STEP 2: Patient/Caregiver Interview – Introduce yourself; focus on asking open-ended questions to elicit information. Resolve any discrepancies uncovered with patient/caregiver.

STEP 3: Documentation – List the current medications the patient is on based on institutional protocol. Document the date/time of when the last dose was taken.

STEP 4: Clinical Evaluation – Review medication list in view of clinical picture and document findings – ADRs, medication-related problems.

Pre-Interview Preparation (Admission Reconciliation Process)

• Review past medication lists in a patient’s EMR and compare it to the most recently available medication list.– Past History and Physical report– Discharge Summary– Other Healthcare facility chart– Prescription claims data

• Research the patient’s past medical history – review past diagnoses and match to medication regimens– Example:

• Diagnosis - Hypertension • Treatment: Is there a medication(s) on board to treat hypertension?

• Pay close attention to high alert medications

• Communicate with other disciplines involved the patient’s care

Patient/Caregiver Interview (Admission Reconciliation Process)

Interview Component Details and TipsIntroduction

Question/answer session

- Introduce yourself in a friendly, professional manner by identifying your name and title - a smile goes along way.

- Inform the patient of what you are there to talk about.

- Ask open-ended questions – Avoid medical jargon

- Assess reliability of information – explore vague responses

- Determine PCP or Retail Pharmacy- Assess adherence

- Thank the patient/caregiver for speaking with you- Ask if the patient/caregiver has any questions for

you.

Conclusion

Patient/Caregiver Interview Questions

• An initial open-ended question about home medications– What medications do you take at home and how do you take them?

• Ask about medications for specific conditions– What medicines do you take for [e.g. high blood pressure]?

• Ask about as needed medications– Which medicines to take only sometimes?– Do you take anything for headaches? Allergies? Sleep? Heartburn?

• Ask about medications that are easily forgotten– Do you apply any creams, ointments, or patches to you skin?– Do you take any eye drops, ear drops, nasal sprays, or inhalers?– Do you take any medicines once a week or month?

• Ask about non-prescription products– Which medicines do you take that do not require a prescription (over-the-counter,

herbals, vitamins, supplements)?

• Assess recent medication adherence in a nonjudgmental manner

Documentation of Home Medication List

• List medications according to Institution-specific protocol (EMR or written chart)

• EMR documentation– Document medication name, dose, route of

administration, and frequency in codified fields

– Avoid free text fields • Review list prior to final confirmation

Clinical Evaluation of Home Medication List

• Review comprehensive home medication list in light of current clinical context– Determine any medication-related problems

• Indication-specific problems• Efficacy• Safety• Adherence

• Document assessment in EMR or chart• Communicate findings with medical team

Summary: Optimizing Admission Reconciliation Process

Objective SkillsStep 1: Obtain a comprehensive Preadmission medication list

Step 2: Avoid Reconciliation Errors

Step 3: Review the medication list in clinical context

- Open-ended interview questions- Knowledge of medication names

(brand and generic) and dosage forms- Ability to leverage Information

systems- Assess adherence

- Perseverance

- Prevent errors of omission and commission

- Recognize therapeutic duplications

- Consider patient and disease factors- Identify any medication-related

problems- Screen for high-alert drugs – more

likely to cause severe harm when used in errorAdapted from: Sponsler KC, et al. Improving medication safety during hospital-based transitions of care. Cleveland Clinic Journal of Medicine 2015;82(6):351-

360.

Home

Healthcare Facility

Home




Key Players Involved in Medication

Reconciliation with an Internal Transfer:

Providers

Nurses

Pharmacists

Patient/caregiver

Features of Internal Hospital Transfers

• Movement/transfer between levels of care Intensive care unit Telemetry floorTelemetry floor Intensive care unit• Changing health status• Geriatric patients• Sudden changes in organ function

– Kidney function– Liver function

• Most common discrepancy = error of omission4

4. Lee JY, et al. Medication reconciliation during internal hospital transfer and impace of computerized prescriber order entry. Ann Pharmacother. 2010;44:1887-1895.

Summary: Optimizing a Hospital Internal Transfer Medication Reconciliation Process

Objective Skills- Review the comprehensive

preadmission medication list with active inpatient orders

Step 2: Avoid Reconciliation Errors (errors of omission and commission)

- Identify discrepancies between preadmission medication list and current inpatient orders.

- Evaluate clinical rationale for temporarily holding medications

- Assure clear communication documented in EMR

- Assure preadmission list is accurate- Follow-up if needed

- Consider patient and disease factors (renal insufficiency)

- Identify any medication-related problems

- Document findings and interventions

Step 3: Review the current inpatient medication list in clinical context

Home

Healthcare Facility

Home




Key Players in Discharge Reconciliation:

Patient/Caregiver

Nurses

Providers

Case managers

Pharmacy personnel

Facts related to Hospital Discharge and beyond:

Nearly 20 % of patients experience adverse events within 3 weeks of discharge.5

Studies have shown that timely in-home or telephone follow-up after discharge can decrease adverse events and health care utilization.6

5. Forster AJ, et al. Ann Intern Med. 2003;138:161-167

6. Jack BW, et al. Ann Intern Med 2009; 150:178-187

Key Findings of Medication Reconciliation at Discharge

Garbage in Garbage out

Preadmission Medication List



Preadmission Medication List

Inpatient Medication List

Discharge Medication List

Nature of the Discharge Process

Ideal

Reality

Medication reconciliation Structured discharge

communication Patient education Follow-up Successful reduction in

readmissions

Project RED7

Care Transitions Trial8

7. Jack BW, et al. A reengineered discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150:178-187

8. Coleman EA, et al. The care transitions intervention: results of a randomized controlled trial. Ann Intern Med. 2006;166:1822-1828

Components of Discharge Medication List

• Readability– Clear language – avoid medical jargon– Use easy-to-read typeface and readable type size (at

least 12 point type)– Incorporate pictures if possible– Use patient’s preferred language

• Medication Information– Include brand and generic names– Include indication for use– Simplify dosing when possible – Clearly define which medications should be stopped

from preadmission list, continued from preadmission list, and newly started upon discharge

Medication Counseling at Discharge

• Focus on key points and highlight changes or additions to regimen.

• Include specific instructions for follow-up and monitoring– How to handle common and serious adverse effects of

medications• Use “teach-back” to confirm clinical understanding• Encourage the patient and caregiver to ask questions• Address barriers to medication adherence• Assure patient has transportation to pharmacy that is

open at time of discharge and that the patient can afford the medications

Barriers to Adherence

Access to Medications

Forgetting to take

medications

Low health literacy

Adverse Effects

• Use generic drugs or lowest-tiered agents on prescription plan

• Simplify regimen• Make sure patient has

prescriptions at discharge

• Encourage use of a single pharmacy

• Arrange transportation to pharmacy or bedside delivery at discharge

• Simplify regimen

• Use long-acting formulations

• Encourage use of pill boxes

• Smart phone app reminders

• Use picture-based education

• Provide education on what to do in case of an adverse effect

Summary: Optimizing Discharge Medication Reconciliation Process

Objective SkillsComparative review - preadmission medication list, inpatient orders, and discharge medication list.

Assure patient/caregiver understanding

- Identify discrepancies between preadmission medication list and current inpatient orders.

- Evaluate clinical rationale for temporarily holding inpatient medications

- Assure clear communication- Patient/caregiver education – new

medications, disease states, patient concerns

- Confirm understanding with “teach-back”

- Assess health literacy- Assure prescriptions can be filled- Leverage information systems- Multidisciplinary, collaborative effort

Handoff to Primary Care Physician and Outpatient pharmacy

Post-Discharge Follow-up

• In-home or telephone follow-up• Time consuming• Tips for follow-up phone call

– Confirm with patient best day to call and phone number to be reached

– Arrange interpreter services if applicable prior to making the call to the patient

– Review medications – preadmission list hospital course Discharge list

– Use a script to prompt questions– Use “Teach-back” to reinforce key concepts

• Objective Understand the need for pharmacist clinical interventions

at transitions in care with Doylestown hospital as a case example.

Introduction





Agenda

Doylestown Health: Medication Reconciliation Process Map

(Patients admitted through Emergency Department)

Unit Nursing Team

ER Nursing Team

Initial Home Med List Active Home Med

ListVerification

Hospital Day 1

Unit Nursing Team

Ongoing Home Med ListUpdate For New

Information

PhysiciansPharmacy

Pharmacy



PhysiciansPhysicians

Admitting physicians reconfirm

medication list with

patient/family

Admitting physicians reconfirm

medication list with

patient/family

Electronic medication

reconciliation

Electronic medication

reconciliation

Pilot studies

ED Pharmacist

Med Rec for

Admittedpatients

Adherenc

escreening

Dosing Consult

s

Drug

Information

MedicationIn-

services

Coderespons

e

ACLS/PALS

certified

PatientCounsel

ing

ADR detection & reporting

Benefits of a Pharmacist in the Medication Reconciliation Process

• Patient Benefits– Improved accuracy of medication list

– Improved patient safety

– Improved continuity of care

– Increased patient engagement in medication use

• Hospital Benefits– Allows ED nurses &

physicians to focus more on stabilizing acute medical conditions

– Gives admitting Providers a comprehensive medication history

– Reduces burden on staff pharmacists to clarify admission orders incorrectly entered in the patient’s EMR

– Improved HCAHPS score

Questions

transitions in care: optimizing medication reconciliation ryan centafont, pharmd clinical pharmacist...

Documents

transitions of care

interfaces of care

health care continuum

health care practitioner

effective patient interview

national patient safety

poor communication

review strategies