1. Medication Reconciliation: Pharmacy Integrated Model Steve A. Carlson, RPh Sara E. Grove, Pharm.D. Northeast Georgia Health System (NGHS) Gainesville, Georgia Best Practice Power Hour

2. NGHS   Private, not-for-profit, community   Accredited by DNV   557 inpatient beds   261 skilled nursing beds   Serves almost 700,000 people in more than 13 northeast Georgia counties

3.   Inpatients 30,364   Outpatients 238,542   Surgeries   Outpatient 10,801   Inpatients 7,466   Emergency Visits 99,456   Deliveries 4,087 Patients Served

4.   32.04 Pharmacists (including management)   6 Clinical Pharmacy Specialists Department of Pharmacy  41 Technicians (3:1 ratio in GA)  Unit-Based Pharmacy Technicians  Cardiology  Critical Care  Internal Medicine  Oncology  Women & Children’s Health  Emergency Medicine  Cardiology  Critical Care  Internal Medicine  Oncology  Women & Children’s Health  Emergency Medicine (2) * Reflects staffing only at the medical center

5.   Customer Service is a major focus of the facility   Patient   Staff   Developed a Unit-Base Pharmacy Technician Model Providing Exceptional Service

6. Unit-Based Pharmacy Technician (UBT) Program   Established in February 2007   Initially 4 Pairs of Technicians   Goals   Optimize Distribution   Establish Direct Communication   Provide Focused Service   Qualified Staff   Certified Technicians   Experienced Senior Staff

7. Review of Events   January 2006: Nurse Managers Interviewed   March 2006: Base-Line Survey Conducted   May 2006: Results Presented   May 2006: Pilot on 2 Floors Conducted   July 2006: Proposal Presented & Approved   November 2006: Initial Deployment   February 2007: Full Implementation   March 2007: Survey Repeated   May 2007: Results Presented   July–August 2007: Focus Groups Met

8. Initial FTE Requirements   7.6 FTE’s; 10 hour shifts 7on / 7off   Open pharmacist position (1 FTE) converted to 2.8 FTE’s   Redeployed 2.0 FTE’s   Requested a net of 2.8 new FTE’s

9. Initial UBT Assignments

10. UBT Responsibilities   Delivery of medications directly to nurse or nurse server   Resolution of missing medications   Facilitating transfer of medications on/off unit with patient   Removal/return of discontinued meds   Automated Dispensing Cabinet troubleshooting/restock

11. UBT Responsibilities   Delivery of cart fill to nurse server   Med error/ADR reporting to pharmacist   Notification of allergy/height/ weight   Monthly nursing unit inspections   Assistance with faxing of orders   Obtain new orders from units and expedite medication needs

12. Customer Service Survey

13. 20062007 Pharmacy Customer Service Survey All Nursing Units - Medical Center

14. Pharmacy Customer Service Survey 20062007 Areas Serviced by Unit-Based Technicians - Medical Center

15. Survey Comments and Suggestions   “These techs are the smartest thing I’ve seen around here in a long time. They are beyond measure – an asset to having quality – acceptable nursing care.”   “Excellent teamwork – assists nurses to complete essential nursing tasks & focus on this vs. non-nursing duties.”   “Go unit based techs! You rock.”

16. Survey Comments and Suggestions   “Still have a problem with medication missing, but turn around time to get it is much better.”   “The morning meds that are due before breakfast…are scheduled at 0730 and this isn’t working well. By the time we get out of report, the breakfast trays have already been passed. Can these meds please be scheduled for 0630?”

17. Reconciliation Process Home Transfer DischargeAdmission Home Med List Created Addressed by MD Reconciled by RPh List Provided to Next Provider of Care Reconciled by MD Addressed & Reconciled by MD New Home Med List Created Communicated to Patient by Nurse

18. Identifying Deficiencies Discharge Medication List Heart Failure Core Measure HF-1 Scores Average Fiscal Year 2008: 53.4% TJC Average: 75.8% Majority of failures due to transcription errors Admission Medication List Staff observed errors and omissions Garbage In / Garbage Out NGHS Performance Improvement Dashboard

19. Medication Reconciliation Responsibilities   Admission Interview patient at admission Document home medication list Print list for physician to address   Discharge Document discharge medication list as specified by physician orders Notify nurse of discrepancies

20. Technician Training   Software Demonstrate Proficiency in Entry   Procedure Identify Discrepancies   Communication Demonstrate Appropriate Body Language Review Principle Identify Barriers

21. Pilot: Heart Failure   Pharmacist Pre-Pilot October to Mid-December 2008   Locations Emergency Department 3 Medical/Cardiac Inpatient Units   Redistribution of Workload Reduced # Beds/UBT Added 3 Positions per Week

22. Pilot UBT Assignments

23. Pharmacy-Based Medication Reconciliation Pilot Starts December 16 th Floors Participating: S3E S4D S4E ED 1) To improve patient safety and care by striving to optimize the medication reconciliation process 2) To demonstrate improvement through increased Heart Failure Core Measure scores Goals: Here to Help Rx Interview admitted patients and document current home medication list If medication history is needed immediately and a pharmacy technician is not available, collect and document current home medication list Record “MD Discharge Medication Orders” in Clinical Profile Resolve discrepancies with physician Pharmacy Tech DutiesNurse Duties Admission Discharge Print “Admission Medication List” and attach it to the chart Notify nursing of any discrepancies Sign “MD Discharge Medication Orders” to indicate completion Counsel the patient on discharge medications and instructions Sign “Patient Discharge Medication List” Coverage from 0700-2300 Late admissions will be completed the following morning Review and sign off “MD Discharge Medication Orders” Here to Help Rx

24. Technician-Assisted Medication Reconciliation NGHS Performance Improvement Dashboard HF-1 ScoreAdjusted Score 2008 Average53.4%-- 1 st Quarter 200975.4%92.1% 2 nd Quarter 200970.1%85% January63.6%77.3% February72.7%86.4% March73.9%91.3%

25. Current UBT Assignments

26. Cumulative HF Scores

27. Cumulative Failure Origin

28. Opportunities for Improvement   Nurse/Technician Clarifications   Developed a formal discrepancy form   Discharge Summary   Development of electronic bridge   Improperly Completed Forms   Form revision

29. Discrepancy Reasons   Therapeutic Interchange   New Prescription   Duplicate Therapy   Medication Not Addressed   No Prescription   Inappropriate Form Completion   Inappropriate Alteration of Form

32. Medication Reconciliation: Pharmacy Integrated Model Steve A. Carlson, RPh Sara E. Grove, Pharm.D. Northeast Georgia Health System (NGHS) Gainesville, Georgia Best Practice Power Hour