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Medication Safety The Role of Medication Reconciliation & Medicine Lists Presenter Name & Organization Objectives • Be familiar with Washington Patient Safety Coalition • Understand where medication reconciliation, My Medicine List, and safe transitions fit into the medication safety strategic plan. • Understand the current regulatory drivers around medication reconciliation, such as The Joint Commission’s National Patient Safety Goal (NPSG) • Advocate and implement medication reconciliation into workflow • Promote patient awareness and utilization of My Medicine List Patient Case • 52 year old man goes to the clinic for a check-in visit with his Specialist provider. • Patient’s electronic chart indicated he was to take 1 tablet of aspirin 325 daily. Patient reported taking 18 tablets of aspirin 325mg daily for shoulder pain. • This is almost 6,000 mg of Aspirin • New pain regimen was discussed About the WPSC The Washington Patient Safety Coalition is dedicated to improving patient safety and reducing medical errors for individuals receiving health care in Washington, in all care settings. Our Vision • Safe care: every patient, every time, everywhere. Our Values • Patient-centered • Systems-oriented and sustainable • Evidence-based • Inclusive • Resource-sensitive Our Goals • We will improve safety within and across all care settings by: • Facilitating the exchange of information about best practices relative to patient safety. • Disseminating new knowledge and new practices. • Supporting coordinated/collaborative efforts and new partnerships. • Raising awareness of the need for safe practices. www.wapatientsafety.org The Concerns Around Medication Safety • 1999 IOM report: estimated that medical errors cause 44,000 to 98,000 preventable deaths and one million additional injuries each year in U.S. hospitals, and cost over $850 billion. • A 2006 follow-up to the IOM study found that medication errors are among the most common medical mistakes, harming at least 1.5 million people every year. According to the study, each year… 400,000 preventable drug-related injuries occur in hospitals 800,000 in long-term care settings 530,000 among Medicare recipients in outpatient clinics Improving Medication Safety: Where to begin? High Alert / High Risk Agents Drug Interactions Adherence/ Compliance Barriers Improved Packaging & Labeling Patient Education Medication Errors Prescriber Education Transitional Care Management Patients at Risk Nearly 40% of patients have ≥ 1 unintended medication discrepancy at hospital admission! A similar proportion are present at transfer within a hospital and in 14% of patients at hospital discharge. Cornish PL et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165:424-429. Medication Reconciliation: A Definition? No standard exists! The Joint Commission recommends… The process of verifying that a patient’s current list of medications (including dose, route, and frequency) is correct and that the medications are currently medically necessary and safe. Greenwald et al. Making inpatient medication reconciliation patient centered, clinically relevant, and implementable: a consensus statement on key principles and necessary first steps. Jt Comm J Qual Patient Saf. 2010 Nov;36(11):504-13, 481. ASHP-APhA Medication Reconciliation Goals Medication reconciliation should be a patient-centered process, taking into account the patient’s level of health literacy and willingness to engage in his or /her personal health care. Target improvement in patient well-being through education, empowerment, and active involvement Achieve by promoting communication among patients and healthcare providers ASHP – APhA Medication Reconciliation Initiative Workgroup Meeting . February 12, 2007 Achieving Medication Safety Goals via Medication Reconciliation Drive Systems (Re)Design and Process Improvement Maximize Use of Technology Facilitate Cultural Change Catalyst Driving Change • WPSC • Regulatory Organizations • Reimbursement Models Healthcare Systems Design: Must Support the Med Rec Process Collect Clarify Change in… • Care Setting • Medications Verify Reconcile Communicate Educate Medication Reconciliation: Not So Simple! HOSPITAL ADMISSION PROCESS DISCHARGE PROCESS COMMUNITY PROCESS Medication Info Sources Pt & Family Clarification/Verification Physicians Pharmacies Care Facilities Medical Records Pre-Admit Outpt Medication List Pre-Admit Outpt Medication List Pre-Admit Outpt Medication List Pt & Family Physicians Outpatient Medication List Inpatient Med List Inpatient Med List 3rd Party Vendors Patient condition & diagnosis Discharge Medication Reconciliation Pharmacies Care Facilities Real Life Example: Inpatient Admission • Patient admitted through ED – ED Not a good setting for collecting information • Triage, stabilize, transfer or discharge • Solution: ED Med Rec Techs – Complete when admitted on unit? • Nurses busy admitting patient • Med Rec challenging and time consuming – Use what was collected in ED? Verify but not thoroughly? • Provider prints off what is in system – Unverified, from last admission – Errors perpetuated on Transfer and at Discharge – Garbage In = Garbage Out Real Life Example: Franciscan Health System • Patient Arrives at ED – ED Med Rec Tech • Interviews patient or caregivers • Records medication information from patient medication bottles • Calls outpatient pharmacies, queries available sources, GH Epic, FMG Elysium, etc., contacts patient’s PCPs • Clarifies information with family or caregiver • Generates a complete and accurate home med list that is reviewed by a pharmacist • List provided to ED or admitting provider to complete medication reconciliation. – Accurate home medication improves transitions in care – Provides a good foundation for Discharge Med Rec Real Life Example: Group Health Post-Discharge Medication Reconciliation Discharge Home Primary Care • Patients identified who are high risk for readmit • Pharmacist calls patient 1 - 3 days post-discharge • Pharmacist updates • Information sent to Clinical Pharmacists for follow up • Med recon and comprehensive medication review •Makes medication recommendations patient’s physician 80% of patients have at least one discrepancy resolved. Safe Transitions Involve Many! • Safe transitions are best when we maximize a multi-disciplinary approach • Group Health: Specialty Medication Reconciliation involves a variety of disciplines – Medical Assistant: medication verification – Specialist: medication review and hand-off to pharmacist – Pharmacist: comprehensive medication reconciliation and communication to patient and appropriate physicians – Primary Care Provider: authorize prescriptions and carry out ongoing care of patient’s therapy INCENTIVIZING CHANGE VIA REGULATORY PROCESS Mandating change and prioritization Technology Adoption The Joint Commission Medication Reconciliation Requirements A 6-year journey to improve patient safety 2005 • TJC introduces NPSG 8 2006 • “Med Rec” required for accreditation 2007 • NPSG minor revisions 2008 • NPSG major revisions planned 2009 • Scoring suspended and some simplification 2010 • New standards created & released 2012 • Implementation of new standard TJC 2011 Medication Reconciliation National Patient Safety Goal #3: the safety of using medications” “Improve NPSG.03.06.01: “Maintain and communicate accurate patient medication information” Applies to: • Hospitals, including Critical Access Hospitals • Ambulatory Care • Office (Ambulatory) Surgery • Home Care • Long-term Care • Behavioral Health The Patient Protection and Affordable Care Act (H.R. 3590) Value-Based Purchasing (VBP) Core Measures (Section 3001) Healthcare-Associated Infections (HAI) (Section 3001) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) (Section 3001) At Risk: 1% in FY2013 growing annually to 2% in FY2017 (70% Core Measures + HAI and 30% HCAHPS) Medicare Reimbursement Hospital Acquired Conditions (HAC) (Section 3008) 5 At Risk: 1% reduction beginning FY2015 At Risk: 1% reduction in FY2013 and will Rise to 3% by FY2015 Readmission Rates (Section 3025) COPD, CABG, PTCA, etc. AMI, PNE, HF Readmissions are… Frequent • 18% of all Medicare hospitalizations are 30-day re-hospitalizations • Average rates are >20% for certain patient populations Potentially avoidable • 76% of Medicare re-hospitalizations were “potentially preventable” Costly • $15B annually in Medicare of which $13B may be unnecessary Actionable for improvement • Research and quality improvement initiatives have demonstrated >30% reduction of 30-day readmission rates for a variety of populations Medications and medication use are often implicated in unexpected readmissions! http://www.medpac.gov/documents/jun07_entirereport.pdf MedPAC 2007 Report to Congress; Promoting Greater Efficiency in Medicare Med Reconciliation & Readmissions How much does a hospital readmit cost? $14,500 Our analysis shows that for every 25 patients that receives med recon postdischarge, 1 hospital readmit is prevented. For the 2012 calendar year, the program will save an estimated 1 million dollars Readmission Rates 37% 40 30% 35 30 25 Number of Patient 20 Readmits 15 21% 11% 10 Comparison: No Med Recon 5 0 Intervention: Med Recon 14 day 30 Day Kilcup M, Schultz D, et al. Post-discharge pharmacist medication reconciliation: Impact on readmission rates and financial savings. J Am Pharm Assoc. 2013: Jan/Feb, 53:1. Opportunities for Pharmacy: Readmissions Preventing Interventions Phase of Care Admission Inpatient Stay Discharge Home Pharmacy Service Provided Perform Admission Assessment Determine factors in admission/readmission • Medication history • Medication reconciliation • Errors of omission (EBM) • Adverse drug events (ADE) • Medication adherence • Medication access Determine post-hospital needs • Where will patient likely receive care? • Who are caregivers? • Barriers to care? Care Optimization Provide effective teaching & enhanced learning • Identify barriers to learning • Medication management • Disease self-management • Medication adherence • Use “Teach Back” method • Provide tools Optimize the medication regimen • Initiate indicated medications • Discontinue unnecessary or unsafe medications • Simplify the medication regimen Prepare for Transition in Care Provide Appropriate Post-Discharge Care Medication regimen review • Medication reconciliation • Provide medication list and related information to: o Patient/caregiver o Physician/medical team o Pharmacy/pharmacist Contact patient/caregiver • Live or virtual visit Verify appropriate postdischarge care plan • Match discharge follow-up to need (readmission risk stratification) • Ensure proper information is provided regarding contact information, action plan for care and symptom or AE management Patient status and medication review • Medication reconciliation • Medication adherence • ADE surveillance • Medication access • Med management/ Disease management Communicate to other providers any pertinent medical information or findings Achieving Medication Safety Goals via Medication Reconciliation Drive Systems (Re)Design and Process Improvement Maximize Use of Technology Facilitate Cultural Change Catalyst Driving Change • WPSC • Regulatory Organizations • Reimbursement Models Achieving Medication Safety Goals via Medication Reconciliation Drive Systems (Re)Design and Process Improvement Maximize Use of Technology Facilitate Cultural Change Catalyst Driving Change • WPSC • Regulatory Organizations • Reimbursement Models “MY MEDICINE LIST” A WPSC Sponsored Project My Medicine List Heighten Public Awareness • Emphasize the need for patients to take an active role in managing their medicines. • The initiative’s goal is for every person to maintain an up-to-date list and to share it with his/her health care provider. My Medicine List What's in a “Medicines” List • • • • • Prescription medications Sample medications Vitamins Herbal & Alternative Meds Nutriceuticals & Dietary Supplements • Over-the-counter drugs • Vaccines • Respiratory therapy-related medications • Parenteral nutrition • Blood derivatives • Intravenous solutions (plain or with additives) • Diagnostic and contrast agents • Radioactive medications Any product designated by the FDA as a drug! How Can You Help? Remember the 3 As • ASK every patient about his or her medicine list at each encounter. • ADVISE your patients to carry a list • ASSIST your patients with resources & tools Refer your patients to mymedicinelist.org for information and resources What you don’t know about your patients could harm them! Thank You!