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

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

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”

• Herbals/ Non-prescription 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)

WHO HAS THE BEST MED LIST ? 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  What is the “truth”? Y. Kwan BScPhm

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?

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

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

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

Getting Organized! What is our commitment to the project? Review the letter of commitment with the team Review the Introduction package Confirm your team Letter of Commitment: The commitment of the team to the project is listed in the letter. Review it with all team members. Introduction Package: The will be to you soon. The finishing touches have been completed and will be ready for dissemination soon. Confirm your team: The sooner the better…assign tasks All of these will be used as reference when you are completing your team charter

First Steps Team Charter 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 Team Charter: Purpose of the project Scope and Boundaries Aim Statements Measures to be tracked timelines and reporting Ideas for change This is a live document which is managed as the team moves through the project. It should include timelines for changes and evaluation As we move through this presentation it will give you information for your team charter We will have some samples to send to you to help you with it. Education: Understand the definitions & terminology of the project, medication reconciliation process, agency policies & procedures, Understand the case for medication reconciliation in the home

Identify your Target Population 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 Project Level Criteria Newly discharged from an acute care facility ( new client , or existing client discharged from acute care facility) At least one prescribed medication Pilot Team Level Criteria All referrals assigned to the trained service providers as determined by the pilot team Service Provider Level Criteria Criteria for the “Target Population” is finalized by the service provider using the Medication Risk Assessment Tool The risk assessment tool will be developed by the pilot team and carried by the trained service providers at all times Medication Risk Assessment Tool This tool will be developed by the team. The questions will refine the target population directed by the scope and boundaries set out in the Team Charter Example: Does the client have 4 or more prescribed medication? Is the client on Warfarin? Does the client have any identified cognitive issues?

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

Selecting Your Sample 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 Remember, they all need it but can you do it for all….So pick and choose

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?

Sample Size Dependent on referral volume Dependent on your target population size Dependent on the number of trained service providers 5 point baseline SUGGESTION Number of trained Service providers: Three trained service providers doing one to two BPMH’s per week will give you a sample size of 12 to 24 per month. Three trained service providers may give you good coverage over holidays, vacation weekends etc. But bottom line you decide being aware that the bottom line in sample size is 5. Anything less will not generate credible measures. The suggested aim of sample size is 10 to 20 clients per month in total, depending on the size of the agency

The Medication Reconciliation Process 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

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 How are we going to manage these challenges? Keep it as simple as possible in our complex world. The fewer the steps the less change for variances and obstacles popping up. We have multiple interface points within our own organization beyond transfer to outside world. Chart in the home. How are we going to manage the transfer of information to the physician for review and confirmation, while still keeping the information in the home wit the client? Remember, keep it simple! Think about carbon copying, the BPMH, tools, consider the cost versus time to transcribe information to fax to physician. We have little control over the physicians, but we can do everything in our power to set the process up for success. Use a standard cover page with a brief introduction of the process asking for review and send back asap. Smaller communities you may want to set up a meeting or teleconference with the physicians and let them know what the project is about As with most people, they will want to know what is in it for them…. well they will have an accurate up to date list of client meds….reduce adverse events…compliance better. Time up front as opposed to time through course of service…already is a process in place….service providers will tell you…all the time they spend chasing down docs….looking in closets will this is reworking the process to increase efficiency. Different way of thinking…engaging all across the continuum

Data Collection 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

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 Keep it as simple as possible Use the tools you already have Use your MedRAT for confirmation of your target population Fax or deliver all your positive MedRat’s to the office

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.

Data Submission: Monthly Electonic Data Collection Tools Will be made available for you. One tool for each measurement: Transfer data to these tools for submission to the CMT this is usually done by the team leader. This is something you should outline in your charter so there is clarity of rolls and tasks Final process for submission is pending

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 YOU SHOULD RECORD ANY FACTORS BY TYPE AND DATE; THIS IS IMPORTANT WHEN YOU ANALYSIS YOUR DATA ONCE IT IS RETURNED TO YOU FROM CMT: YOU WILL BE ABLE TO SUBSTANTIAL DIPS AND SURGES IN YOUR RUNNING CHARTS Volume of Referrals: no control over this but the trained service provider can be proactive and alert the scheduler to assign her new admissions if the volume is low. And Just do as much sampling as possible Lack of trained staff: If your target population does not reflect your volume of referrals then perhaps you might want to entertain the idea of increasing your complement of trained service providers. Or perhaps you have a service provider gone on vacation or off sick…need enough staff to balance this Implementation of change: expect completion time to be slower until the service provider becomes more adapt at using the tool and process. Vacation: Well we need to continue tracking regardless but sampling may reduce not because of a lack of trained service providers but because of time restraints

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 LETS REVIEW THE TOOLS: REMEMBER KEEP IT SIMPLE: YOUR MIGHT WANT TO START WITH THREE TOOLS FOR COLLECTION MedRAT: Use this tool to identify your target population. Submit all your positive RAT scores to the central office for recording in the master data collection tool. This tool should include the client’s name and health card number so it can be recorded on the master sheet BPMH FORM: Our colleagues out west used the BPMH form as a collection tool as well. Lets learn from them and adopt this approach where/when possible. The balance of the data needed can be extracted from this form if there is a place for it. However when you are first starting you may be using the tools you currently have so you may need to develop a tool in the mean time until you start implementing changes in you BPMH tools Monthly Master sheet: This is where you are going to collect all your data. Record all the names for clients who have positive RAT scores. As the BPMHs come in look for the client name and complete the balance of the data collection. You may notice at times that the RAT and the BPMH may arrive together. Some BPMH may be delayed and some may not arrive at all which is an indication that the client was not selected as a sample.

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

Get Started! 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!