1. Clinical Training: Medication Reconciliation
VNAA Best Practice for
Home Health

2. Learning Objectives
To understand why medication reconciliation is important to providing quality care
To understand the three step process for improving medication reconciliation
Identification of barriers patients may have when taking medications and ways to overcome them

3. Why is medication reconciliation so important?
The number one problem in treating illnesses is patients’ failure to take prescribed medications correctly, regardless of age
In the U.S., 50-70% of patients do not take medications properly
10% of hospital admissions relate to taking meds properly, 23% of all nursing home admissions

4. Statistics 22% take less than what is prescribed
12% do not fill their prescription at all
12% do not take the medication at all after buying the prescription
29% stop taking the medication before it runs out
% take other people’s medication

6. Medication reconciliation
Takes on new importance as an increasing number of patients are prescribed multiple medications by multiple physicians
With each care transition example hospital to home, hospital to SNF, SNF to home the risk of medication problems increases. Patients often have several ordering providers which also increases the chances for confusion and discrepancies. Proper medication reconciliations can reduce medication discrepancies and potentially dangerous interactions which can lead to unwanted ER visits, hospital stays or other poor outcomes.

7. *Adapted from the Institute for Healthcare Improvement
Medication Reconciliation* is the process of identifying the most accurate list of all medications a patient is actually taking — including name, dosage, frequency, and route. The information is then used to determine which medications the patient should be taking per physician orders.
The Medication Reconciliation process for home care has three basic steps:
Verify - Collect an accurate medication list
Clarify - Clarify any questions about drug/dose/frequency
Reconcile - Communicate with physician about any identified medication questions or concerns
*Adapted from the Institute for Healthcare Improvement
Medication reconciliation is a formal process in which health care professionals partner with
clients and families to ensure accurate and complete medication information transfer at
interfaces of care.
It involves a systematic process for obtaining a medication history, and using that information to
compare to medication orders to identify and resolve discrepancies. It is designed to prevent
potential medication errors and adverse drug events
Medication reconciliation is NOT the clinician only looking at the patient’s hand written list or discharge summary without looking at every bottle the patient takes. Never assume the patient list/discharge list is correct or reflects what the patient is actually taking.

8. Step 1: Verify
Collect a COMPLETE list of ALL medications that the patient is currently taking. This includes:
Prescription medications
OTC medications, i.e., aspirin, acetaminophen, NSAIDs, Benadryl for sleep
Culturally-based home remedies, such as:
Ginseng (for physical and mental performance, infection resistance)
Chamomile tea (for sleep/anxiety)
OTC herbal products, such as:
St. John’s Wort (for depression, stress, anxiety)
Senna (for constipation)
Black Cohosh (for menopause symptoms)
Dietary supplements such as Calcium (to prevent osteoporosis)
Vitamins such as Niacin, Vitamin E, Vitamin D
Scripts to help verify the medications a home care patient is taking
1.In addition to the medications ordered by your doctor are you taking any other pills, vitamins or minerals?
2.Do you have any other pills or other medications in your:
Kitchen
Bedroom
Bathroom
Pantry or linen closet
Anywhere else?  \
Do you take any vitamin or mineral supplements?
Do you take any herbal remedies like Sleepy Time Tea?
Do you regularly take an over-the-counter medication for:
Constipation Diarrhea Pain like a headache, arthritis, muscle aches Sleep Heartburn Upset stomach Skin problems
*******************************************************************
1. Do you take any other pills on a regular or occasional basis other than what your doctors have ordered?
2. Any other over the counter medications such as pain relievers or laxatives?
3. Do you take any vitamins or herbal supplements?
What prescription medications are you currently taking?
What other non-prescription medications do you take?
If response is none/nothing:
Verify: Any herbals, vitamins, over-the-counter pain medicine like Tylenol, Ibuprofen? Any laxatives? 
Hint: Many elderly people take 81mg aspirin a day, Tylenol PM at bedtime, laxative & supplements (multivitamin, iron)

9. Step 1: Verify
It is important to specifically ask about the use of non-prescription medications and preparations – patients often do not consider things such as vitamins “medications” and will not volunteer that they are taking them
Other tips for obtaining more complete medication lists at the start of home care:
Tell the patient/family BEFORE the first visit to collect all of the patient’s medications and have them ready for the nurse to see.
Ask the patient what help they think they might need in managing their medications.

10. Step 2: Clarify
Clarify medication names, doses, frequencies, and to identify combinations that may be contraindicated or medications that seem to be inappropriate
In the Clarify step, a key goal is to identify potentially serious drug-drug interactions or therapeutic duplication within the patient’s medication list
Therapeutic duplication is present when the patient’s medications include two or more medications from the same chemical family or therapeutic class
A possibility for drug-drug interaction (DDI) is present when the patient’s medications include two or more medications with the potential to interact negatively with one another
Our software allow us to check for interactions. Assess the patient, listen to what they tell you. Could some of their symptoms be related to medication problems?

11. After entering medications into the clinical system, you are asked to check for adverse reactions. If patients have interactions that equal a 1 or 2 you are to call the physician to notify them of the alert and document. Adverse reactions of use your clinical judgment based on clinical symptoms the patient has.

12. Step 2: Clarify
Besides looking for therapeutic duplication and drug-drug interactions, the reconciliation process should identify any potentially inappropriate medications. Certain medications should generally be avoided in older persons – although a physician may decide that their use for an individual patient’s specific clinical circumstance is appropriate. One such list of medications is called the Beers Criteria.
We use the Beers criteria which is based on a consensus derived from an expert panel that reviews scientific literature. The list is intended to assist clinicians in adopting evidence-based prescribing practices. When you encounter a patient receiving a potentially inappropriate medication, refer to the Beers criteria, clearly articulate your concerns with a description of assessment findings to the prescriber.

13. Step 3: Reconcile Reconcile the medications with the physician
If the patient’s medication list is free from therapeutic duplication, potentially inappropriate medications, and no dose, route or frequency questions have been identified, the completed medication list can be entered in section 10 on the HCFA Form 485 and sent to the physician for verification and signature
If a question or potential problem has been identified, the nurse (or therapist) is responsible for ensuring that these are reported to the physician, and for obtaining clarification or revised orders

14. Facilitating physician response
Clinicians are trained to write care plans more narrative in nature. Physicians however are trained to use “headlines” or bullet points notations. As a result there are different approaches when communicating.

15. SBAR
SBAR is a communication model that is easy to remember, adaptable to the situation, painless to learn and most importantly, effective.
Situation - What is happening with the patient?
Background- What is the clinical background?
Assessment- What do I think the problem is?
Recommendation- What would I recommend?
The SBAR Technique promotes systematic and efficient communication between health care professionals about a particular patient condition or issue.
SBAR stands for:
Situation
Background
Assessment
Recommendation
SBAR provides a script that can be used to organize information for communicating collaboratively with a physician about a patient. It is effective both verbally and in writing.

16. Adherence and medication management
To improve the patient’s management of complicated medication regimens, home health agency staff need to understand what gets in the way of adherence and understanding
Assessment needs to be more than the ability to take medications
Ask patients open-ended
questions about their medications
to get more telling answers.
After collecting all medications, ask
patients – container by container –
what each drug is, why they’re taking
it, how often they’re taking it and if
it’s effective. Doing so will reveal if
patients are truly compliant and if the
medications are doing what’s expected
to manage symptoms, Rambusch
says. Simply posing “yes” or “no”
questions about medications could
lead the patient to give the answer
they expect clinicians want to hear.

17. Adherence vs. Persistence
Adherence: the extent to which a person takes medications as prescribed
Persistence: the ability of a person to continue to take medications for the intended course of therapy

18. Factors contributing to adherence
Health literacy: Failure to understand directions on the label
Regimen complexity
Dosing frequency more often than twice a day
Remembering doses and refills
Fear of side effects; 45% people do not take their meds because of the side effects
I feel okay now, why should I take it?
Cost
Knowing your resources is important. How can pharmacists, OT, PT, SLP, MSW help in some of these instances?

19. Health literacy
Health literacy is the ability to read, understand and act on health information in order to make appropriate health decisions. Poor health literacy results in medication errors, impaired ability to remember and follow treatment recommendations, and reduced ability to navigate within the health care system.
Only 12 percent of adults have Proficient health literacy, according to the National Assessment of Adult Literacy.  In other words, nearly nine out of ten adults may lack the skills needed to manage their health and prevent disease.  Fourteen percent of adults (30 million people) have Below Basic health literacy.  These adults were more likely to report their health as poor (42 percent) and are more likely to lack health insurance (28 percent) than adults with Proficient health literacy.6
Low literacy has been linked to poor health outcomes such as higher rates of hospitalization and less frequent use of preventive services (see Fact Sheet: Health Literacy and Health Outcomes). Both of these outcomes are associated with higher healthcare costs.

20. Health literacy
Older adults with low health literacy may have trouble reading health information material, following prevention instructions, understanding basic medical instructions, and adhering to medication regimens. A study of patients aged 60 years and older at two public hospitals found that 81% could not read and understand basic materials such as prescription labels.
Foundation: Health Literacy - YouTube

21. Conclusion
"Medicine used to be simple, ineffective and relatively safe."
"Now it is complex, effective, and potentially dangerous."
Sir Cyril Chantler
The goal of medication reconciliation is improvement in patient well-being through education, empowerment, and active involvement in the accurate transfer of medication information throughout transitions along the healthcare continuum. By promoting communication among patients and healthcare providers, medication reconciliation can resolve discrepancies in medication regimens and improve patient safety.