Transcript Inpatient Track: Transitions in Care

Transitions in Care:
Optimizing Medication
Reconciliation
Ryan Centafont, PharmD
Clinical Pharmacist
Doylestown Hospital
October 29, 2015
Objectives
 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.
Agenda
Introduction
Why Medication
Reconciliation Matters
 Recall the approach to conducting
an effective patient interview.
Barriers to Medication
Reconciliation
 Review strategies for optimizing
medication reconciliation at
admission, transfer, and discharge
from a hospital.
Optimizing
Medication Reconciliation
 Understand the need for
pharmacist clinical interventions at
transitions in care with Doylestown
hospital as a case example.
Medication Reconciliation
at Doylestown Hospital
Question
Which of the following are barriers to successful
medication reconciliation?
A) Low health literacy of a patient or caregiver
B) Well-defined roles in medication reconciliation
process among staff members
C) Lack of “buy in” of Providers in medication
reconciliation process
D) A and C
E) 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?
Primary Care
Physician
Hospice Care
Long Term
Care facility
Specialist
Patient/Caregiver
Community
Pharmacy
Hospital
Home Care
Urgent Care
Center
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
Meaningful Use
Readmissions
Requirements
• Confusion at
discharge & poor
adherence
• Electronic collection
and sharing
Joint Commission Accreditation
• Incentive payments
2011 – Incorporated into National
Patient Safety Goal #3
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
Outcomes Across
Care Settings
Measurement
Patient
Safety
Clinical
Quality
Patient
Satisfaction
Medication Reconciliation
MTM
Agenda
Introduction
Why Medication
Reconciliation Matters
Barriers to Medication
Reconciliation
Optimizing
Medication Reconciliation
Medication Reconciliation
at Doylestown Hospital
• Objective
Understand the barriers
and solutions to
successful medication
reconciliation
Barriers to Successful Medication
Reconciliation
System Barriers
Provider Barriers
Patient 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
Integration of Health Information Technology
System Factors
• Unclear roles and expectations
• Insufficient staffing
• Poorly designed electronic tools that do not provide userfriendly 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
Culture of Accountability
Coordinated Communication
Standardization
Integration of Health Information Technology
Keys to Overcoming Barriers to
Medication Reconciliation
Interdisciplinary
Approach
Culture of
Accountability
Quality
Improvement
Patient-Centered
Medication Reconciliation
Coordinated
Communication
Integration of
HIT
Standardization
Agenda
Introduction
Why Medication
Reconciliation Matters
Barriers to Medication
Reconciliation
Optimizing
Medication Reconciliation
Medication Reconciliation
at Doylestown Hospital
• Objectives
 Recall the approach to
conducting an effective
patient interview
 Review strategies for
optimizing medication
reconciliation at
admission, transfer, and
discharge from a hospital
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
Key Players in Admission
Reconciliation:
Patient/Caregiver
Home
Pharmacy personnel
Admission
Reconciliation
Nurses
Providers
Admission Reconciliation Facts:
Medications ordered
and internal transfers
Healthcare Facility
Discharge
Reconciliation
Errors in medication histories are
the most common source of
discrepancies, affecting up to twothirds 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.
Home
3. Dobranski S. et al. The Nature of Hospital Prescribing Errors. Br J Clin Goverance 2002;
7:187-193
Obtaining the Best Possible Medication
History (BPMH) – A Systematic Approach
STEP 4: Clinical Evaluation – Review medication
list in view of clinical picture and document findings
– ADRs, medication-related problems.
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 2: Patient/Caregiver Interview – Introduce yourself; focus
on asking open-ended questions to elicit information. Resolve
any discrepancies uncovered with patient/caregiver.
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.
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
Introduction
Details and Tips
- 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.
Question/answer session
- Ask open-ended questions – Avoid medical
jargon
- Assess reliability of information – explore vague
responses
- Determine PCP or Retail Pharmacy
- Assess adherence
Conclusion
- Thank the patient/caregiver for speaking with you
- Ask if the patient/caregiver has any questions for
you.
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 Institutionspecific 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
Step 1: Obtain a comprehensive
Preadmission medication list
Skills
-Open-ended interview questions
-Knowledge of medication names (brand
and generic) and dosage forms
- Ability to leverage Information systems
-Assess adherence
- Perseverance
Step 2: Avoid Reconciliation Errors
- Prevent errors of omission and
commission
- Recognize therapeutic duplications
Step 3: Review the medication list
in clinical context
- Consider patient and disease factors
- Identify any medication-related problems
- Screen for high-alert drugs – more likely
to cause severe harm when used in error
Adapted 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
Admission
Reconciliation
Medications ordered
and internal transfers
Key Players Involved in
Medication
Reconciliation with an
Internal Transfer:
Providers
Nurses
Healthcare Facility
Pharmacists
Discharge
Reconciliation
Home
Patient/caregiver
Features of Internal Hospital Transfers
• Movement/transfer between levels of care
Intensive care unit  Telemetry floor
Telemetry 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
- Review the comprehensive
preadmission medication list with
active inpatient orders
Skills
- Identify discrepancies between
preadmission medication list and current
inpatient orders.
- Evaluate clinical rationale for
temporarily holding medications
- Assure clear communication
documented in EMR
Step 2: Avoid Reconciliation Errors
(errors of omission and
commission)
Step 3: Review the current
inpatient medication list in clinical
context
- 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
Key Players in Discharge
Reconciliation:
Patient/Caregiver
Home
Admission
Reconciliation
Nurses
Providers
Case managers
Pharmacy personnel
Medications ordered
and internal transfers
Facts related to Hospital Discharge
and beyond:
Nearly 20 % of patients
experience adverse events within
3 weeks of discharge.5
Healthcare Facility
Discharge
Reconciliation
Studies have shown that timely inhome 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
Home
Key Findings of Medication
Reconciliation at Discharge
Preadmission
Medication List
Discharge
Reconciliation
Garbage in
Garbage out
Discharge Reconciliation
Preadmission
Medication List
Inpatient Medication
List
Discharge
Medication List
Nature of the Discharge Process
Project RED7
Care Transitions Trial8
Ideal
Medication reconciliation 
Structured discharge
communication  Patient
education  Follow-up 
Successful reduction in
readmissions
Reality
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
•
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
Forgetting to
take
medications
•
Simplify
regimen
•
Use longacting
formulations
•
Encourage
use of pill
boxes
•
Smart phone
app reminders
Low
health
literacy
•
Adverse
Effects
Use picturebased
education
•
Provide
education on
what to do in
case of an
adverse effect
Summary: Optimizing Discharge Medication
Reconciliation Process
Objective
Comparative review - preadmission
medication list, inpatient orders, and
discharge medication list.
Skills
- Identify discrepancies between
preadmission medication list and current
inpatient orders.
- Evaluate clinical rationale for
temporarily holding inpatient medications
- Assure clear communication
Assure patient/caregiver
understanding
-Patient/caregiver education – new
medications, disease states, patient
concerns
- Confirm understanding with “teach-back”
- Assess health literacy
Handoff to Primary Care Physician
and Outpatient pharmacy
- Assure prescriptions can be filled
- Leverage information systems
- Multidisciplinary, collaborative effort
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
Agenda
Introduction
Why Medication
Reconciliation Matters
Barriers to Medication
Reconciliation
Optimizing
Medication Reconciliation
Medication Reconciliation
at Doylestown Hospital
• Objective
 Understand the need for
pharmacist clinical
interventions at
transitions in care with
Doylestown hospital as a
case example.
Doylestown Health:
Medication Reconciliation Process Map
(Patients admitted through Emergency Department)
ER Nursing
Team
Initial Home
Med List
Admitting
physicians
reconfirm
medication list
with
patient/family
Electronic
medication
reconciliation
Unit Nursing
Team
Pharmacy
Unit Nursing Team
Physicians
Pharmacy
Active Home Med
List
Verification
Ongoing Home Med List
Update For New
Information
Hospital Day 1
Pilot studies
Physicians
Discharge
Reconciliation
ED
Pharmacist
Med Rec
for
Admitted
patients
Adherence
screening
Dosing
Consults
Evaluate
MedRelated
Problems
Pharmacist
Note filed
in EMR
Drug
Information
Code
response
Medication
In-services
ACLS/PALS
certified
Patient
Counseling
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