Medication Reconciliation in Home Care: Partnering with Patients for Safety

1. Medication Reconciliation in Home Care:Partnering with Patients for Safety Debbie Conrad RN, VON Canada and Olavo Fernandes PharmD, ISMP Canada SHN ! Medication Reconciliation Home Care Pilot Oct 14, 2008

2. Creating the most “up to date” medication record (best possible medication history) Compare: Medication Information from all other sources Patient and Family Interview • Examples: • Medication vial inspection • Referral record • Community pharmacy • Hospital Discharge Summary “medication discrepancies that require clarification” document “up to date” medication record (BPMH) Review and follow up where indicated

3. Process For Identifying “Medication Discrepancies That Require Clarification” In Home Care Creating the most “up to date” medication record (best possible medication history) Compare : • Patient / Family Interview ( a systematic and comprehensive, medication history interview- representation/ snapshot in time of what medication the client is actually taking) Vs. • all other available sources of medication information (home care referral records, inspection of medication vials/ samples, community pharmacy information, hospital medication discharge summaries, unfilled prescriptions etc) • IDENTIFY: Medication Discrepancies That Genuinely Require Clarification”

4. Process For Identifying “Medication Discrepancies That Require Clarification” In Home Care • Note process must include patient/ family medication history interview • Reconciliation process allows for clinician professional judgment to discern which “discrepancies genuinely require clarification “ • Herbals/ Non-prescription (over-the counter drugs)- will not classify as a discrepancy requiring clarification – unless prescribed by physician (or other prescriber)

5. Patient Interview Labels on Rx Vials Medication Lists Family MD Patient’s Actual Medication Use Medical chart Medication wallet cards Community pharmacist Patient’s Medication Regimen Prescribed WHO HAS THE BEST MED LIST ?  What is the “truth”? Y. Kwan BScPhm

6. What is a Best Possible Medication History ? Creating the most “up to date” medication record (best possible medication history) • A medication history obtained by a clinician which includes a thorough history of regular medication use (prescription and nonprescription) • Uses information from multiple sources: medication vials, hospital discharge summary, patient or caregiver interview, inspection of prescription vials, community pharmacy follow-up or current med list printed by community pharmacy • What about a just a “quality” patient interview?

7. Medication History:Information Sources include….. • Provincial drug data base • Patient interviews • Hospital discharge summary • MD chart notes • Standardized forms • Family MD records • Inspection of Medication vials • Review of community pharmacy records • Review of previous home care records

10. Common Challenges & Solutions • Communication barriers • Non – English/ French speaking patients • Level of consciousness/ cognitive impairment – post op/ acutely ill • Solution: family members , interpreters, community pharmacy • Patient understanding of need to obtain an accurate medication history • Solution: proactively explain importance, empower patient to actively participate

11. Common Challenges & Solutions • Poor perception of what is a medication? • Patients may not commonly list : OTCs, herbals, vitamins, non-traditional , street drugs • Solution: effective prompting/ follow/ up questions • Time/ Resources needed for a BPMH • Solution: Active Preparation: review other sources/ primary medication histories prior to interview to streamline process/ anticipate discrepancies • Medication Use Medication prescribed • Solution: Focus on “medication use” • Solution: Seek clarification : community pharmacy, primary care physicians, family

12. What is our commitment to the project? Review the letter of commitment with the team Review the Introduction package Confirm your team Getting Organized!

13. Understand the definitions and terminology of the project Understand the Medication Reconciliation Process Understand your policies around charting and Med Reconciliation Team Charter Access/enlist the support of your local manager/director of quality Review the background paper on Medication Reconciliation in Home Care First Steps

14. Clients newly discharged from acute care and have at least one prescribed medication Client assigned to Trained Service Providers Clients with a positive Med RAT Score Identify your Target Population

15. Who Will Identify the Target Population? The designated trained service provider

16. You have identified your client as being with in your target population The service provider will decide whether it is appropriate to continue with the BPMH Selecting Your Sample

17. Factors Effecting your decision on Sample Selection • Is the client able to participate in the interview process for BPMH? • Is family available? • Is the situation appropriate to carry out the interview? • Do you have the time? • Is it feasible to return and complete it another visit?

18. Sample Size • Dependent on referral volume • Dependent on your target population size • Dependent on the number of trained service providers • 5 point baseline

19. Identify eligible client Decision include as sample? Interview client/family Gather information from all sources Record Meds in BPMH form Fax to Dr Return to client as most up to date medication record signed by physician The Medication Reconciliation Process

20. Challenges to Medication Reconciliation Process in Home Care • Complexity of Home Care Systems, Multiple interface points • Chart in the home • Physician inclusion/compliance • Financial/Time Restraints • Paradigm shift • Other

21. What data needs to be collected to satisfy the measures to be monitored? The size of the target population The size of the sample population The number of BPMH completed The time it takes to complete the BPMH The number and coding of discrepancies Data Collection

22. Suggestions for Data Collection: Keep it Simple! Use your Med RAT as a collection tool for your target population. Submit all of your positive Med Rats to your designated person for recording on a master sheet in your office

23. Data Collection: Suggestions • Record your data on your BPMH form. • When faxing the BPMH to the physician for review, also fax a copy to the designated person to be recorded on the master sheet.

24. Data Submission: Monthly

25. Identify Factors Which Impact Data Collection • Low /high volume of referrals • Number of trained Service Providers • Implementation of change: tools process • Weather • Vacation, Holidays, Weekends

26. Data Collection Tools • Medication Risk Assessment Tool MedRAT to identify your target population • Tool for delivering the balance of data from the home to your master sheet • Master sheet

27. SHN! Home Care Pilot Measures • Percentage of Eligible Clients with a Best Possible Medication History (BPMH) conducted by a Home Care clinician • Time to complete Best Possible Medication History (BPMH) in Home Care • Percentage of Eligible clients with at least one discrepancy that requires clarification • Classification or characterization of actual discrepancies that require clarification • Also serves as a communication and documentation tool to other clinicians

28. Get your tracking tools ready Start your baseline data collection Allow your normal referral process and service provider assignment to occur Your designated service providers will take it from there. Apply the medication reconciliation process using your present tools and processes Identify opportunities for change! Get Started!