1. Introduction to the Medicines Reconciliation care bundle
The aim of this session is to introduce the concept of care bundles and how they drive improvement , The session should cover:
What are they
How they work - sharing the experience from SIPC
To highlight the care bundle practices will be using and the rationale for it
Highlight the frequency and sample size of data collection
Demonstrate the data collection process

2. Aims of session Introduce the Meds Rec Care Bundle
Discuss measures, operational definitions and rationale.
Discuss data collection process and frequency
Discuss ways to involve patients
Share resources, challenges and learning
The aim of this session is to introduce the concept of care bundles and how they drive improvement , The session should cover:
What are they
How they work - sharing the experience from SIPC
To highlight the care bundle practices will be using and the rationale for it
Highlight the frequency and sample size of data collection
Demonstrate the data collection process

3. Medicines Reconciliation – what is it?
National Definition
“The process that the healthcare team undertakes to ensure that the list of medication, both prescribed and over the counter, that I am taking is exactly the same as the list that I or my carers, GP, Community Pharmacist and hospital team have. This is achieved, in partnership with me, through obtaining an up-to-date and accurate medication list that has been compared with the most recently available information and has documented any discrepancies, changes, deletions or additions resulting in a complete list of medicines accurately communicated”
This slide states the national definition of meds rec – another, more simplistic definition is ‘making sure the discharge Rx is compared with the prescribing record – any clinical decisions made clearly documented. In the most simplistic of terms from a practice perspective it’s spot the difference with clear documentation and communication’

4. Medicines Reconciliation – why is it important?
Patient Safety!
Lots of evidence of patient harm in literature:
72% of adverse events after discharge due to medications (Foster et al 2004)
38% of readmissions considered to be medicines related, 61% of these preventable (Witherington etc al 2008)
14% of pts > 65 years old are discharged with medication discrepancies and have a higher risk of readmission (Kohn et al 2007) etc etc etc……
19.3% of GP negligence claims relate to prescribing and medication (3.8% of these due to supplying incorrect or inappropriate medication)

5. Medicines Reconciliation – why am I here?!
Want to reduce patient harm and improve patient safety relating to medicines
Meds rec one piece of this wider “safer medicines” workstream
Will do meds rec already within your practice but
1) is there a standard process?
2) is it safe and reliable?
3) could it be improved?
4) is it done for “every patient every time”?

6. Perception versus Reality
Be open minded – you may think you have a reliable process and this may be the case - but often perception and reality are quite different. Once you start testing you might be surprised at your results.

7. Medicines Reconciliation in primary care
How do we perform meds rec accurately?
Develop standard reliable process for dealing with discharge information in your practice
Record that meds rec has been done (read code)
Record action taken on any changes (read code(s))
Record discussion of any changes with pt (read code(s))
Do this using a “care bundle”….

8. Medicines Reconciliation – care bundle measures
Has the Immediate Discharge Document (IDD) been workflowed on the day of receipt?
Has medicines reconciliation occurred within 2 working days of the IDD being workflowed to the GP?
Is it documented that any changes to the medication have been acted on?
Is it documented that any changes to the medication have been discussed with the patient or their representative within 7 days of receipt?
Have all the above measures been met?

9. Medicines Reconciliation Care Bundle –
Data Collection
Data collected is for local use, to allow practice teams to gain a better understanding of their systems and make the necessary changes.
Data is displayed in a run chart and allows you to see improvements over a period of time.
Data for improvement - not judgement.
This slide stresses that the data collected should be used for improvement, not judgement

10. Medicines Reconciliation – local GG&C practice results
Target 90%
General improvements to process: small tests of change with PDSA cycles
Improvement – stable but not reliable
Beginning to see reliable process?
This slide shows data from 6 pilot practices in GG&C. You can see from the start of the work the collated practice results achieved about 40% bundle compliance. Data to January this year shows a 97% compliance. Add a caveat in the data here as there are only returns from 3 practices in Jan.
The difference here is practices were carrying out meds rec on ALL their discharges – except one practice who had approximately 80 discharges a month, so they were concentrating on their patients aged over 75. So, meds rec carried out on all discharges and 10 were sampled per month for compliance with the care bundle.
Ideally, the run chart should be annotated with a bit of detail about what has influenced the shift – whether it is good or bad. Summarising Nov –Feb – this showed practices beginning to look at where they were falling down in the individual measures and making small tests of changes and PDSA cycles to improve their process. Apr-Aug – we can see there is the beginning of a standard process but it’s not at the level of reliability we want. Sep 12 – big drop in data – this was due to the implementation of Trakcare - this fundamentally changed how practices had to process their Dx Rxs and the compliance rate fell.
Trakcare!

11. Medicines Reconciliation
In addition to practice looking at their own processes some also audited the accuracy of the Dx Rxs themselves.

12. GG&C discharge “issues”
We know issues can arise from problems on Dx Rxs and some of the pilot practices did document Dx Rx accuracy this along with their corresponding care bundle data. However, we know there can be problems from the acute side but this is very much about concentrating on our own processes and things that we can immediately improve. The data has been fed back to secondary care and equally they have some data on the accuracy on admission data from ECS. This is not about trying to blame each other for problems but if we can all work on improving out processes they will have an all round benefit for the system and ultimately for patients.
We can see from the snapshot the elements of the Dx Rx that help us carry out meds rec in primary care were the most poorly completed. With the introduction of Trakcare and the clearer recoding of meds stopped etc should hopefully improve this picture.

13. Medicines Reconciliation – practical hints and tips
Collecting care bundle compliance data on 5 patients per month
Prioritise patients over 75 years old on 10 or more medicines
if insufficient patient numbers in this cohort per month, reduce the number of medicines or reduce the age
First data return in June – consider using first couple of months to determine your patient cohort and think about your systems and processes
Docman can be used to find your discharged patients
Using EMIS/Vision standard reporting template may make it easier for you to data collect/measure
Info on reporting mechanism to follow – national template being developed
If you have a small number of Dxs per month then suggest carry out meds rec on ALL Dxs. If large no of Dxs per month then select a smaller pt cohort i.e. over 75years on 10 or more meds. Not prescriptive here – practice to identify their high risk pts. Sometimes by defining a smaller cohort may produce an additional step/screen at the front desk but appreciate if you have many Dxs per month the higher risk pts should be prioiritised.
Then sample 5 per month

14. Medicines Reconciliation – practical hints and tips
Measure 1
Difficult to give exact hints and tips as how practices process discharge Rxs will vary depending on how they receive them…..
"Workflow" does not necessarily mean using electronic methods or Docman. This wording relates to whatever existing process you have in place to move the necessary written/electronic paperwork to the relevant personnel for timeous action
Important point is that the day it was “workflowed” is clearly visible when it comes to data collection
Usually an admin/receptionist function

15. Medicines Reconciliation – practical hints and tips
Measure 2
Strongly recommend this is done by a clinician as likely clinical decisions will be made on a discharge prescription
Use Read code #8B318
This is set up in EMIS template/Vision guideline
You don’t have to use read codes however needs to be clearly recorded to aid data collection

16. Medicines Reconciliation – practical hints and tips
Measure 3
Likely this will be completed at same time as Measure 2 - clinician to document any changes to medicines on discharge
All read codes available on same EMIS template/Vision guideline
Some practices may wish to use synonyms
Again important point is it is easy to find when it comes to data collection
Tick N/A only if there are no changes to the meds following discharge – this equates to a Yes for the care bundle compliance

17. Medicines Reconciliation – practical hints and tips
Measure 4
This is the measure most practices struggle with
Practices have been inventive about how to communicate changes
Gold standard = face to face or telephone
Note on the repeat slip of changes
Letter to patient
Some GPs ask competent member of admin staff to contact patient with changes
Method will depend on patient
Use read code #8B3S0
Most practices struggle with but from which we have best examples of patient benefit. For purposes of this measure contacting the community pharmacy does not count as compliance with this measure - however in some cases it will be prudent to do so particularly if pt on a dosette box.
Measure 5 is obviously compliance with all 4 elements of the care bundle.

18. Measure 5 Have all measures been met? Yes or No
Bundle compliance is a team effort and needs support from admin and all those involved in your meds rec process in the practice
Can be collated by anyone in team – admin, practice manager, GP, nurse….
Important thing is to look at your data to identify potential improvements to the process: small tests of change and PDSA

19. Medicines Reconciliation – what’s in it for you?!
Bundles, Trigger Tool and Safety Climate Survey recognised evidence for GP appraisal
Safety is core to revalidation
Standard robust reliable process
reduced variation
more efficient process
workload benefits
less stress
Improved practice team working
Other benefits have been identified as
Doing the best for your patients
More confidence in your systems
Less things going wrong
Less stress
Better Interface working
Fewer adverse events
Fewer Admissions
Safe effective prescribing
Fewer Falls/ UTIs/Pressure ulcers

20. Medicines Reconciliation – what’s in it for you?!
GG&C acute services also concentrating on meds rec
Whole system approach to improving meds rec has primary care, secondary care and ultimately patient benefits
Potentially fewer admissions
Who wouldn’t want to improve patient safety……?
At this point, you may wish to show delegates the video clip of Margaret, talking about her experience of meds rec

21. Care bundles Shed new light on our current practice
Act as a catalyst for improvement in care
Can lead to increased awareness
This slide summarises the positive effects care bundles can have

22. Any Questions?