Medication Reconciliation in Home Care:Medication Reconciliation in Home Care:Partnering with Patients for SafetyPartnering with Patients for Safety

Debbie Conrad RN, VON Canada and Olavo Fernandes PharmD, Debbie Conrad RN, VON Canada and Olavo Fernandes PharmD, ISMP ISMP CanadaCanada

SHN ! Medication Reconciliation Home Care Pilot Oct 14, 2008SHN ! Medication Reconciliation Home Care Pilot Oct 14, 2008

Creating the most “up to date” medication Creating the most “up to date” medication record (best possible medication history)record (best possible medication history)

Patient and Family Interview

Medication Information from all

other sources

document

“up to date” medication

record (BPMH)

“medication discrepancies that

require clarification”

Compare:Compare:

Review and follow

up where indicated

Examples:

•Medication vial inspection

•Referral record

•Community pharmacy

•Hospital Discharge Summary

Process For Identifying “Medication Discrepancies That Process For Identifying “Medication Discrepancies That

Require Clarification” In Home CareRequire Clarification” In Home Care

Creating the most “up to date” medication record (best possible Creating the most “up to date” medication record (best possible medication history)medication history)

Compare : Compare : • Patient / Family InterviewPatient / Family Interview ( a systematic and ( a systematic and

comprehensive, medication history interview- comprehensive, medication history interview- representation/ snapshot in time of what medication the representation/ snapshot in time of what medication the client is actually taking) client is actually taking)

Vs.Vs.• all other available sources of medication informationall other available sources of medication information

(home care referral records, inspection of medication vials/ (home care referral records, inspection of medication vials/ samples, community pharmacy information, hospital samples, community pharmacy information, hospital medication discharge summaries, unfilled prescriptions medication discharge summaries, unfilled prescriptions etc)etc)

• IDENTIFY: IDENTIFY: Medication Discrepancies That Genuinely Medication Discrepancies That Genuinely Require Clarification” Require Clarification”

Process For Identifying “Medication Discrepancies That Process For Identifying “Medication Discrepancies That

Require Clarification” In Home CareRequire Clarification” In Home Care

•• Note process must include Note process must include patient/ family patient/ family medication historymedication history interview interview

•• Reconciliation process allows for Reconciliation process allows for clinician clinician professional judgmentprofessional judgment to discern which to discern which “discrepancies genuinely require “discrepancies genuinely require clarification “clarification “

•• Herbals/ Non-prescription Herbals/ Non-prescription (over-the counter drugs)- will not classify as a (over-the counter drugs)- will not classify as a

discrepancy requiring clarification – unless discrepancy requiring clarification – unless prescribed by physician (or other prescriber)prescribed by physician (or other prescriber)

• Patient Interview Patient Interview • Labels on Rx VialsLabels on Rx Vials• Medication Lists Medication Lists • Family MD Family MD

Patient’s Actual Patient’s Actual Medication UseMedication Use

• Medical chartMedical chart• Medication wallet Medication wallet

cardscards• Community pharmacistCommunity pharmacist

Patient’s Medication Patient’s Medication Regimen PrescribedRegimen Prescribed

What is the “truth”?

WHO HAS THE BEST MED LIST ?WHO HAS THE BEST MED LIST ?

Y. Kwan BScPhmY. Kwan BScPhm

What is a Best Possible What is a Best Possible Medication HistoryMedication History ? ?

Creating the Creating the most “up to date” medication most “up to date” medication recordrecord (best possible medication history) (best possible medication history)

• A medication history obtained by a clinician A medication history obtained by a clinician which includes a thorough history of regular which includes a thorough history of regular medication use (prescription and medication use (prescription and nonprescription)nonprescription)

• Uses information from multiple sources: Uses information from multiple sources: medication vials, hospital discharge summary, medication vials, hospital discharge summary, patient or caregiver interview, inspection of patient or caregiver interview, inspection of prescription vials, community pharmacy follow-prescription vials, community pharmacy follow-up or current med list printed by community up or current med list printed by community pharmacypharmacy

• What about a just a “quality” patient What about a just a “quality” patient interview?interview?

Medication History:Medication History:Information Sources include…..Information Sources include…..

• Provincial drug data baseProvincial drug data base• Patient interviewsPatient interviews• Hospital discharge summaryHospital discharge summary• MD chart notesMD chart notes• Standardized formsStandardized forms• Family MD recordsFamily MD records• Inspection of Medication vialsInspection of Medication vials• Review of community pharmacy recordsReview of community pharmacy records• Review of previous home care recordsReview of previous home care records

Common Challenges & Common Challenges & SolutionsSolutions

• CommunicationCommunication barriers barriers– Non – English/ French speaking patientsNon – English/ French speaking patients– Level of consciousness/ cognitive Level of consciousness/ cognitive

impairment – post op/ acutely illimpairment – post op/ acutely ill• Solution:Solution: family members , interpreters, family members , interpreters,

community pharmacycommunity pharmacy

• Patient Patient understandingunderstanding of need to of need to obtain an accurate medication historyobtain an accurate medication history

• Solution:Solution: proactively explain importance, proactively explain importance, empower patient to actively participateempower patient to actively participate

Common Challenges & Common Challenges & SolutionsSolutions

• Poor perceptionPoor perception of what is a medication? of what is a medication? – Patients may not commonly list : OTCs, Patients may not commonly list : OTCs,

herbals, vitamins, non-traditional , street drugsherbals, vitamins, non-traditional , street drugs• Solution:Solution: effective prompting/ follow/ up questions effective prompting/ follow/ up questions

• Time/ ResourcesTime/ Resources needed for a BPMH needed for a BPMH– Solution:Solution: Active Preparation: review other Active Preparation: review other

sources/ primary medication histories prior to sources/ primary medication histories prior to interview to streamline process/ anticipate interview to streamline process/ anticipate discrepanciesdiscrepancies

• Medication UseMedication Use Medication prescribed Medication prescribed– Solution:Solution: Focus on “medication use” Focus on “medication use”– Solution:Solution: Seek clarification : community Seek clarification : community

pharmacy, primary care physicians, familypharmacy, primary care physicians, family

Getting Organized!Getting Organized!

What is our commitment to What is our commitment to the project?the project?

• Review the letter of Review the letter of commitment with the teamcommitment with the team

• Review the Introduction Review the Introduction packagepackage

• Confirm your teamConfirm your team

First StepsFirst Steps

• Understand the definitions Understand the definitions and terminology of the and terminology of the projectproject

• Understand the Medication Understand the Medication Reconciliation ProcessReconciliation Process

• Understand your policies Understand your policies around charting and Med around charting and Med ReconciliationReconciliation

• Team CharterTeam Charter

• Access/enlist the Access/enlist the support of your local support of your local manager/director of manager/director of qualityquality

• Review the background Review the background paper on Medication paper on Medication Reconciliation in Home Reconciliation in Home CareCare

• Clients newly discharged from acute Clients newly discharged from acute care and have at least one prescribed care and have at least one prescribed medicationmedication

• Client assigned to Trained Service Client assigned to Trained Service ProvidersProviders

• Clients with a positive Med RAT Clients with a positive Med RAT ScoreScore

Identify your Target Identify your Target PopulationPopulation

Who Will Identify the Target Who Will Identify the Target Population?Population?

The designated trained service The designated trained service providerprovider

• You have identified your client as being You have identified your client as being with in your target populationwith in your target population

• The service provider will decide The service provider will decide whether it is appropriate to continue whether it is appropriate to continue with the BPMHwith the BPMH

Selecting Your SampleSelecting Your Sample

Factors Effecting your Factors Effecting your decision on Sample decision on Sample

SelectionSelection• Is the client able to participate in the Is the client able to participate in the

interview process for BPMH?interview process for BPMH?• Is family available?Is family available?• Is the situation appropriate to carry Is the situation appropriate to carry

out the interview?out the interview?• Do you have the time?Do you have the time?• Is it feasible to return and complete it Is it feasible to return and complete it

another visit?another visit?

Sample SizeSample Size

• Dependent on referral volumeDependent on referral volume

• Dependent on your target population sizeDependent on your target population size

• Dependent on the number of trained Dependent on the number of trained service providersservice providers

• 5 point baseline5 point baseline

The Medication The Medication Reconciliation ProcessReconciliation Process

• Identify eligible clientIdentify eligible client• Decision include as sample?Decision include as sample?• Interview client/family Interview client/family • Gather information from all sourcesGather information from all sources• Record Meds in BPMH formRecord Meds in BPMH form• Fax to DrFax to Dr• Return to client as most up to date Return to client as most up to date

medication record signed by physicianmedication record signed by physician

Challenges to Medication Challenges to Medication Reconciliation Process in Reconciliation Process in

Home CareHome Care

• Complexity of Home Care Systems, Complexity of Home Care Systems, Multiple interface pointsMultiple interface points

• Chart in the homeChart in the home

• Physician inclusion/compliancePhysician inclusion/compliance

• Financial/Time RestraintsFinancial/Time Restraints

• Paradigm shiftParadigm shift

• Other Other

Data CollectionData Collection

What data needs to be collected to satisfy What data needs to be collected to satisfy the measures to be monitored?the measures to be monitored?

• The size of the target populationThe size of the target population• The size of the sample populationThe size of the sample population• The number of BPMH completedThe number of BPMH completed• The time it takes to complete the BPMHThe time it takes to complete the BPMH• The number and coding of discrepancies The number and coding of discrepancies

Suggestions for Data Suggestions for Data Collection: Keep it Simple!Collection: Keep it Simple!

Use your Med RAT as a collection tool Use your Med RAT as a collection tool for your target population. for your target population.

Submit all of your positive Med Rats to Submit all of your positive Med Rats to your designated person for recording your designated person for recording on a master sheet in your officeon a master sheet in your office

Data Collection: SuggestionsData Collection: Suggestions

• Record your data on your BPMH Record your data on your BPMH form.form.

• When faxing the BPMH to the When faxing the BPMH to the physician for review, also fax a copy physician for review, also fax a copy to the designated person to be to the designated person to be recorded on the master sheet. recorded on the master sheet.

Data Submission: MonthlyData Submission: Monthly

Identify Factors Which Impact Identify Factors Which Impact Data CollectionData Collection

• Low /high volume of referralsLow /high volume of referrals

• Number of trained Service ProvidersNumber of trained Service Providers

• Implementation of change: tools Implementation of change: tools processprocess

• WeatherWeather

• Vacation, Holidays, WeekendsVacation, Holidays, Weekends

Data Collection ToolsData Collection Tools

• Medication Risk Assessment Tool Medication Risk Assessment Tool MedRAT to identify your target MedRAT to identify your target populationpopulation

• Tool for delivering the balance of Tool for delivering the balance of data from the home to your master data from the home to your master sheetsheet

• Master sheetMaster sheet

SHN! Home SHN! Home Care Pilot MeasuresCare Pilot Measures

1.1. Percentage of Eligible Clients with a Best Percentage of Eligible Clients with a Best Possible Medication HistoryPossible Medication History (BPMH) (BPMH) conducted by a Home Care clinicianconducted by a Home Care clinician

2.2. Time to complete Best Possible Time to complete Best Possible Medication HistoryMedication History (BPMH) in Home Care (BPMH) in Home Care

3.3. Percentage of Eligible clients with at Percentage of Eligible clients with at least one discrepancy that requires least one discrepancy that requires clarificationclarification

4.4. Classification Classification or characterization of actual or characterization of actual discrepancies that require clarificationdiscrepancies that require clarification

• Also serves as a communication and documentation tool to Also serves as a communication and documentation tool to other cliniciansother clinicians

• Get your tracking tools readyGet your tracking tools ready• Start your baseline data collectionStart your baseline data collection• Allow your normal referral process and service Allow your normal referral process and service

provider assignment to occurprovider assignment to occur• Your designated service providers will take it from Your designated service providers will take it from

there. there. • Apply the medication reconciliation process using Apply the medication reconciliation process using

your present tools and processesyour present tools and processes• Identify opportunities for change!Identify opportunities for change!

Get Started!Get Started!