1. Continuity of Care Components of a Meaningful Primary Care Visit Pre-VisitVisitPost-VisitInter-Visit Review notes – your last note, any notes by other MDs in the interim, ER or discharge summaries Inform patient of their PCP and nurse – provide resources (business card and team photo composite) Assign PCP in EMRComplete timely DC summary including the PCP name and H & P. Review interim labsReview all meds (purpose, frequency, dose, other) with patient and give them a copy of the updated med list Document diagnostic tests and studies ordered and pending (IP) and follow up on them If patients’ meds change when admitted based on MUSC’s Automatic Therapeutic Substitution, change them back to patient’s insurance formulary at the time of discharge Review interim studies – ex. mammogram, stress test, colonoscopy, etc. Give the patient a medication bag and encourage taking it with them to all provider visits Notify UIM PCP when seeing another provider’s patient by using the “.cc code.” (OP) Visit or call the patient during hospitalization when notified of their admission Review any consultsLook up provider codes in EMR through knowledge base. Set up any needed health maintenance Notify patient of test results

2. Continuity of Care Patients 65 years and older have multiple medical problems, are on multiple medications, and are seen by multiple providers. Having a primary care physician, communicating among all providers, and reconciling medications are all essential for quality patient care. Ask the patient… 1. What are the names of the medications (including OTC, vitamins, herbal supplements and eye drops) you are currently taking? 2. How do you take your medications and how much have you been taking? 3. Do you understand what the medication is for? 4. Where do you get your prescriptions filled? MD action… 1. Compare home list to the list in the patient’s chart. 2. Ensure dose and frequency are the same and there is a clear indication for every medication. 3. If patient doesn’t understand what meds are for, educate using plain, non-medical language; speak slowly; break down information into short statements. 4. Call the pharmacy if there is any discrepancy between the patients’ reported meds and your list. Rectify in the patient’s chart. Medication Reconciliation Steps References: Wenger, N.S. and R.T. Young (2007) “Quality Indicators for Continuity and Coordination of Care in Vulnerable Elders.” JAGS 55:S285-292. Varkey, P. et al (2007) “Improving Medication Reconciliation in the Outpatient Setting.” Jt. Comm J on Quality & Patient Safety 33:5. Funding provided by D.W. Reynolds Foundation Obtain medication list from patient Obtain medical record medication and problem list Identify discrepancies Include updated list in clinic note Give patient a copy of updated medication list Document updated medication list Optimize the list Reconcile list Call pharmacy or call family Consolidate meds Incorporate into med list Enumerate all meds Evaluate ongoing need of each med.