1. “Presented to” Georgia Critical Access Hospitals October 9, 2013 Kristine Gleason, MPH, RPh - Clinical Quality Leader, Northwestern Memorial Hospital Vicky Agramonte, RN, MSN - Project Manager, Healthcare Quality Improvement Program, IPRO Medication Reconciliation in Rural Hospital Settings

2. Objectives Describe the benefits of a medication reconciliation process and linking with other current initiatives. Provide an overview of the MATCH Toolkit for implementing a sustainable medication reconciliation process. Understand the importance of medication reconciliation at high- risk transition periods.

3. Why Medication Reconciliation?

4. Medication Reconciliation Process Goal to decrease medication errors and patient harm by: 1. Obtaining, verifying, and documenting patient’s current prescription and over-the-counter medications; including vitamins, supplements, eye drops, creams, ointments, and herbals 2. Comparing patient’s pre-admission/home medication list to ordered medicines and treatment plans to identify unintended discrepancies 3. Discussing unintended discrepancies (e.g., those not explained by the patient’s clinical condition or formulary status) with the physician for resolution 4. Providing and communicating an updated medication list to patients and to the next provider of service at discharge Adapted from The Joint Commission National Patient Safety Goal 03.06.01

5. Institute of Medicine “Preventing Medication Errors” At least 1.5 million preventable adverse drug events (ADEs) occur in the U.S. annually in all settings, not including errors of omission. Errors and ADEs are a “very serious cause for concern” in hospitals. Phases with the highest errors: prescribing & administration. Estimated 400,000 in-hospital preventable ADEs / year. Cost per ADE: $8,750 (2006 dollars) – Cost increases when extrapolated to 2013 dollars Preventing Medication Errors: Quality Chasm Series (2007). Committee on Identifying and Preventing Medication Errors, Philip Aspden, Julie Wolcott, J. Lyle Bootman, Linda R. Cronenwett, Editors.

6. Current Evidence to Reduce Readmissions: Implementing Bundled Interventions Source: Hansen et al. Interventions to Reduce 30-Day Rehospitalization: A Systematic Review. Ann Intern Med. 18 October 2011;155(8):520-528 Pre-Discharge Intervention Bridging Interventions Post-Discharge Intervention Patient education Medication Reconciliation Discharge planning Scheduling follow-up appointment Transition coaches Physician continuity across settings Patient-centered discharge instruction Follow-up telephone calls Patient-activated hotlines Timely communication with next provider of service Timely follow-up with ambulatory provider Note: Individual components of these change packages have not been tested by themselves and might not reduce the risk for 30-day rehospitalization.

7. Avoiding Readmissions: Preventing Adverse Events (AE) After Hospital Discharge Study of 400 consecutive hospitalized general medicine patients discharged home – 19% had an AE within 3 weeks of discharge – 66% of AEs were adverse drug events (ADE) – Most ADEs were preventable or ameliorable System modifications recommended by study authors: – Evaluate patients prior to discharge to identify unresolved problems – Educate patients about drug therapies, side effects, and what to do if new or worsening signs/symptoms – Improve monitoring of therapies – Improve monitoring of patients’ overall condition Source: Forster et al. The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Ann Intern Med. 2003;138:161-167.

8. Achieving Synergies: Linking Medication Reconciliation with Other Current Initiatives

9. Does Medication Reconciliation Impact the Patient Experience? Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Domains: Communication with Nurses Communication with Doctors Responsiveness of Hospital Staff Pain management* Communication about medicines* Discharge information* Cleanliness of hospital environment Quietness of hospital environment Overall rating of hospital Willingness to recommend hospital *Impacted by Medication Reconciliation Source: HCAHPS Home Page. Available at: http://www.hcahpsonline.org/home.aspxhttp://www.hcahpsonline.org/home.aspx

10. During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. When I left the hospital, I clearly understood the purpose for taking each of my medications. Scale: Strongly disagree, Disagree, Agree, Strongly agree New HCAHPS Care Transition Questions Effective January 1, 2013

11. “Bundling” Medication Reconciliation with Current Initiatives Med History, Reconcile Order, Transcribe, Clarify Procure, Dispense Deliver AdministerMonitor Educate, Discharge Phases of Medication Management Identifying Opportunities to “Bundle” Medication-related Initiatives EDAdmission Intra- hospital Transfer Discharge Post- Discharge Care Transitions Reducing medication-related readmissions Process of Care (Core) Measures Meaningful Use of EHRs involving medications Medicare Beneficiary Quality Improvement Project (MBQIP) Effective communication/handoff practices with next provider of service Avoiding preventable ADEs TJC Med Mgmt Standards and NPSGs (e.g., high alert meds, anticoagulants) Patient Experience (HCAHPS) Follow-up Phone Calls Post-Discharge

12. Medications At Transitions and Clinical Handoffs: Introduction to the MATCH Toolkit

13. MATCH Toolkit: Step-by-Step Guide to Improving Medication Reconciliation MATCH Toolkit, with customizable, actionable information, is available at: http://www.ahrq.gov/qual/match/ http://www.ahrq.gov/qual/match/ match.pdf

14. Guiding Principles Clearly define roles and responsibilities. Standardize, simplify, and eliminate unnecessary redundancies. Make the right thing to do the easiest thing to do. Develop effective forcing functions, prompts, and reminders during the appropriate time within workflow. Educate workforce, and patients, families, and caregivers. Ensure process design meets all pertinent local laws or regulatory requirements.

15. Medication Reconciliation Challenges Lack of standardized process, clear ownership Communication failures Coordination gaps Non-formulary medications and therapeutic interchanges Lack of standardized medication list “one source of truth” document

16. Limited Pharmacy Resources Consultant pharmacist with minimal involvement (3-10 hours/wk) Onsite pharmacist (40 hours/wk) Remote pharmacist coverage (24/7) Combination of onsite and remote

17. Designing the Process: “One Source of Truth” Single list documents home medications Standardized across the facility Maintained in a consistent location in the medical record All providers are empowered to update the list as new and more accurate information is available Used at admission, transfer, and discharge for medication reconciliation

18. Engaging the Community Community education on the importance of maintaining a home medication list – Community health fairs – Hospital newsletter – On-hold message on hospital phone system – Flu clinics – Hospital Web site

19. Engaging the Community CAH’s are in a unique position to make an impact in medication safety at the community level Patient accountability for the maintenance of a home medication list – Completion of list while waiting in ED – For planned surgery - incorporate into pre-surgery registration – Community education on keeping a medication list in a consistent spot for EMS – Outpatient pharmacy validates discharge lists – Community physicians request and validate medication list at every patient appointment

20. Medication Reconciliation - Recommendations Examine current medication reconciliation process – Identify and close failure gaps – Incorporate information technology solutions Clinical pharmacist intervention upon admission and discharge for those patients identified as high risk OTC, vitamins and other supplements taken at home should be: – Included on patients admission medication list – Assessed for continuation upon discharge, and – Listed on discharge medication instructions if clinically appropriate

21. Vicky Agramonte, RN, MSN Project Manager Healthcare Quality Improvement Program Island Peer Review Organization, Inc. (IPRO) Albany, NY 12211-2370 (518) 426-3300 X115 vagramonte@ipro.org Kristine Gleason, MPH, RPh Clinical Quality Leader Northwestern Memorial Hospital Chicago IL 60611 312.926.9172 kmgleaso@nmh.org Questions and Discussion THANK YOU! If you want to learn more about IPRO, please visit our website at: http://www.ipro.org. If you want to learn more about Northwestern Memorial Hospital, please visit our website at http://www.nmh.org.