Reconcile Medications


Effective medication reconciliation reduces discrepancies and minimizes potentially dangerous interactions that can lead to hospitalization and other negative outcomes.
 Medication reconciliation involves implementing a systematic process to obtain a medication history, and using that history to compare medication orders to identify and resolve discrepancies. In hospice, medication reconciliation may include initiating discussion of drug discontinuation, and planning for symptom management.

Relevant Measures - Home Health:
  • How often the home health team taught patients (or their family caregivers) about their drugs
  • How often patients got better at taking their drugs correctly by mouth
  • Medication reconciliation (IMPACT Act)
  • For hospice, medication management influences patient experience scores
Medication-Related Top Tip: Develop program for geriatric pharmacy consult for high risk patients; this may be done in collaboration with discharging hospital
 
Best Practice Model Intervention:
  • Design a process to intervene in common discrepancies and define roles and responsibilities.
  • Utilize the three-step process: verify, clarify, reconcile.
  • Identify whether or not the patient is on high-risk medications.
  • Complete medication reconciliation on the first or second visit.
  • Clarify any discrepancies within 24-48 hours.
  • Utilize tools, such as Tips for Conducting a Patient Medication Interview.
  • Incorporate frontloading in the first two to four weeks with three to four visits in each week for patients on high risk medications
  • For hospice patients, collaborate with clinicians, the patient and caregiver to reduce and simplify the medication regimen to include only essential medications
  • Implement continuous QI by mapping the agency’s current medication reconciliation process and identifying barriers to high performance
Goal: Medication reconciliation is performed consistently at frequency specified by the agency and by all staff
Barriers:  
  • Inconsistent agency staffing
  • Med Rec is challenging in therapy-only cases, particularly if there is scope of practice issue in the state
  • Insufficient training for physical therapist on new drugs
  • Professional practice barriers: in some states PTs are prohibited from providing med teaching. 
Best Practice Interventions:
  • Involve Agency’s Nurse Council in updating templates for lists and reviewing medication education information
  • Use interdisciplinary model of care so that all practitioners reinforce medication teaching
  • Assess patient health literacy, cognitive function
  • Plan for next visit - the RN should document patient/caregiver training that needs to be reinforced or started
  • Review medication management practices and quality improvement at staff meetings
  • Audit records for consistent practice
  • Implement an agency-wide policy for med reconciliation every visit
  • Enhance communication between disciplines regarding Plan of Care for medication teaching
  • Provide scripting for medication teaching and management
  • Provide staff education for both nurses and therapists, including training on how to effectively use teach-back
  • Provide support and education for PTs to more effectively perform medication reconciliation. Also educate therapists on ways to educate patients about their medications.
  • Request order for skilled nursing if cases are therapy-only and the patient has multiple or complex medications
  • Offer onsite and remote staff education 'connecting the dots' between medications, OASIS accuracy, medication reconciliation practices, completing a medication list in the home and educating patients on medications
Goal: Medication teaching targeted to patient goals, preferences, literacy level
Best Practice Interventions:
  • Teach clinicians to elicit patient goals, concerns, and understanding of medications to develop a shared medication management plan that is meaningful to the patient and caregiver;
  • Use interdisciplinary model of care: all practitioners reinforce medication teaching. This may include RN, SW, rehabilitation and if possible, a geriatric pharmacist.
  • Develop medication plan of care based on patient goals, and that accommodates patient / caregiver health literacy and cognitive function
  • Enhance communication between disciplines regarding Plan of Care for medication teaching
  • At each teaching visit, plan for next the visit.  The clinician should document patient/caregiver training to be reinforced or started
  • Request order for skilled nursing if cases are therapy-only and the patient has multiple or complex medications
  • Implement an agency-wide policy for med reconciliation every visit
  • Develop medication teaching and assessment templates (many can be found on the internet)
  • Provide scripting for medication teaching and management
  • Review the agency’s medication management strategy periodically at staff meetings
  • Provide staff education for both  nurses and therapists, including training on how to effectively use teach-back
  • Train staff using scenarios of patients with diverse learning needs; make leave-behind patient education materials available to staff (including electronic materials)
  • Always include caregivers in medication teaching, as evidence links informal caregivers with increased readmission risk
  • Audit records for consistent medication reconciliation and teaching practices
  • Use a low literacy literate medication lists and educational materials that are easy to use by all patients
  • Post the medication list and agency contact information in patient's residence or facility
Goal: Maximize the medication regimen for simplicity and effectiveness
Barriers:
  • The number of medications and differences in lists can be very confusing for both staff and patients/families.
  • MD may not return calls promptly to resolve.
 Best Practice Interventions:
  • Consider consults with geriatric pharmacist for complex cases
  • Use SBAR (Situation, Background, Assessment, Recommendation) format to communicate with physicians, including a recommendation on the action desired by the clinician to improve safety, reduce complexity
  • Develop pharmacy and pharmacist partnerships.  This may include coordinating with a retail pharmacist for a medication review, or engaging pharmacists to conduct retrospective analysis for patients experiencing medication related ED visits or complications
  • Invest in pharmacist review for patients with complex medication regimens. Some agencies are using pharmacists for review of med profiles with > 5 or 10 medications.
  • Communicate with physicians about approaches to improve safety, reduce complexity of medications, using SBAR (Situation, Background, Assessment, Recommendation) format to communicate
  • Host quarterly staff meetings to address medications, featuring a guest pharmacist to new medications and review trends
  • Use “high alert medication monitoring” e.g. flag patients taking medications most associated with ED use or readmissions
  • Recommend that pharmacy consultations that are included in coordination of care practices 
  • Offer the option of compliance packaging instead of pill boxes to assure medication safety
  • Consider partnering with a compliance packaging company
  • Recommend that consults that are included in coordination of care.  
Goal: Patients /caregivers have access to medications, understand what they are taking and why, and use them consistently
Barriers:
  • Meds changed or not available at hospital discharge
  • Inconsistent caregiver availability
  • Staff caring for patients residing in facilities may not adequately document knowledge of medications or participate in HH training
  • Underlying depression impacts understanding, adherence
Best Practice Interventions:
  • Collaborate with hospitals for protocol to send patients home with medications
  • Prior to home health discharge, identify plan for accessing meds, which may include identifying a pharmacy to deliver medications
  • Engage social work to help patients with medication costs
  • Provide training on strategies for patient education using scenarios of patients with diverse learning needs; make leave-behind patient education materials available to staff (including electronic materials)
  • Assess patient / caregiver learning ability and modify teaching as needed
  • Use a low literacy literate medication list – easy to use by all patients
  • Use stoplight tools for patient education and reference
  • Post lists and agency contact information in patient's residence or facility

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