Medication Reconciliation & Presenter Name & Organization Medication Safety The Role of Medication Reconciliation & Medicine Lists Presenter Name & Organization

Objectives Be familiar with Washington Patient Safety Coalition Understand where medication reconciliation, My Medicine List, and safe transitions fit into the medication safety strategic plan. Understand the current regulatory drivers around medication reconciliation, such as The Joint Commission’s National Patient Safety Goal (NPSG) Advocate and implement medication reconciliation into workflow Promote patient awareness and utilization of My Medicine List

Patient Case 52 year old man goes to the clinic for a check-in visit with his Specialist provider. Patient’s electronic chart indicated he was to take 1 tablet of aspirin 325 daily. Patient reported taking 18 tablets of aspirin 325mg daily for shoulder pain. MEG This patient had not had the opportunity yet to tell a healthcare professional how much aspirin he was taking until the medical assistant walked through his medication list with him. When the discrepancy was identified, it was sent to a med reconciliation pharmacist for review The pharmacist called the patient The patient did not know that it was a very dangerous daily dose of aspirin (well over the recommended maximum of 400%) The patient had never told his doctor that he was taking that much The pharmacist determined that acetaminophen was a safer choice for this patient The pharmacist gave him a recommended dosing plan with acetaminophen If this patient continued to take 6,000 mg of aspirin daily, he was great increasing his chance of bleed. The patient learned the importance of knowing his medications and following his recommended medication list. He also learned to tell his healthcare professionals exactly what he was taking. This is almost 6,000 mg of Aspirin New pain regimen was discussed

About the WPSC www.wapatientsafety.org The Washington Patient Safety Coalition is dedicated to improving patient safety and reducing medical errors for individuals receiving health care in Washington, in all care settings. Our Vision Safe care: every patient, every time, everywhere. Our Values Patient-centered Systems-oriented and sustainable Evidence-based Inclusive Resource-sensitive Our Goals We will improve safety within and across all care settings by: Facilitating the exchange of information about best practices relative to patient safety. Disseminating new knowledge and new practices. Supporting coordinated/collaborative efforts and new partnerships. Raising awareness of the need for safe practices. Our Values Patient-centered: The methods used and promoted by the Coalition will be driven by the needs of the patient. Systems-oriented and sustainable: The Coalition will focus on system changes that create and sustain a safe environment. Evidence-based: The Coalition will strive to promote methods and activities that are evidence-based, while accommodating new research and emerging applications. Inclusive: The Coalition’s work will recognize the diversity of our community and will strive to include all populations. Resource-sensitive: The Coalition will be sensitive to the resources required to implement and sustain change. www.wapatientsafety.org

The Concerns Around Medication Safety 1999 IOM report: estimated that medical errors cause 44,000 to 98,000 preventable deaths and one million additional injuries each year in U.S. hospitals, and cost over $850 billion. A 2006 follow-up to the IOM study found that medication errors are among the most common medical mistakes, harming at least 1.5 million people every year. According to the study, each year… 400,000 preventable drug-related injuries occur in hospitals 800,000 in long-term care settings 530,000 among Medicare recipients in outpatient clinics

Improving Medication Safety: Where to begin? Drug Interactions High Alert / High Risk Agents Adherence/ Compliance Barriers Patient Education Improved Packaging & Labeling Medication Errors Prescriber Education Transitional Care Management Transitional Care Management

Patients at Risk Nearly 40% of patients have ≥ 1 unintended medication discrepancy at hospital admission! A similar proportion are present at transfer within a hospital and in 14% of patients at hospital discharge. A series of interventions, including medication reconciliation, introduced over a seven-month period, successfully decreased the rate of medication errors by 70% and reduced adverse drug events by over 15%. Whittington J, Cohen H. OSF Healthcare’s Journey in Patient Safety. Quality Management in Health Care. 2004;13(1):53-59. Cornish PL et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165:424-429.

Medication Reconciliation: A Definition? No standard exists! The Joint Commission recommends… The process of verifying that a patient’s current list of medications (including dose, route, and frequency) is correct and that the medications are currently medically necessary and safe. Greenwald et al. Making inpatient medication reconciliation patient centered, clinically relevant, and implementable: a consensus statement on key principles and necessary first steps. Jt Comm J Qual Patient Saf. 2010 Nov;36(11):504-13, 481.

ASHP-APhA Medication Reconciliation Goals Medication reconciliation should be a patient-centered process, taking into account the patient’s level of health literacy and willingness to engage in his or /her personal health care. Target improvement in patient well-being through education, empowerment, and active involvement Achieve by promoting communication among patients and healthcare providers ASHP – APhA Medication Reconciliation Initiative Workgroup Meeting . February 12, 2007

Achieving Medication Safety Goals via Medication Reconciliation Drive Systems (Re)Design and Process Improvement Drive Systems (Re)Design and Process Improvement Catalyst Driving Change WPSC Regulatory Organizations Reimbursement Models Maximize Use of Technology Facilitate Cultural Change

Healthcare Systems Design: Must Support the Med Rec Process Collect Clarify Change in… Care Setting Medications Verify Reconcile Communicate Educate

Medication Reconciliation: Not So Simple! DISCHARGE PROCESS HOSPITAL ADMISSION PROCESS COMMUNITY PROCESS Medication Info Sources Pt & Family Clarification/Verification Physicians Pharmacies Pre-Admit Outpt Medication List Pre-Admit Outpt Medication List Pre-Admit Outpt Medication List Pt & Family Care Facilities Physicians Outpatient Medication List Pharmacies Medical Records Inpatient Med List Inpatient Med List Care Facilities 3rd Party Vendors Patient condition & diagnosis Discharge Medication Reconciliation

Real Life Example: Inpatient Admission Patient admitted through ED ED Not a good setting for collecting information Triage, stabilize, transfer or discharge Solution: ED Med Rec Techs Complete when admitted on unit? Nurses busy admitting patient Med Rec challenging and time consuming Use what was collected in ED? Verify but not thoroughly? Provider prints off what is in system Unverified, from last admission Errors perpetuated on Transfer and at Discharge Garbage In = Garbage Out Example of process at Franciscan Health System

Real Life Example: Franciscan Health System Patient Arrives at ED ED Med Rec Tech Interviews patient or caregivers Records medication information from patient medication bottles Calls outpatient pharmacies, queries available sources, GH Epic, FMG Elysium, etc., contacts patient’s PCPs Clarifies information with family or caregiver Generates a complete and accurate home med list that is reviewed by a pharmacist List provided to ED or admitting provider to complete medication reconciliation. Accurate home medication improves transitions in care Provides a good foundation for Discharge Med Rec Example of improved process from Franciscan Health System

Real Life Example: Group Health Post-Discharge Medication Reconciliation Discharge Home Primary Care Example provided by Group Health Patients identified who are high risk for readmit Information sent to Clinical Pharmacists for follow up Pharmacist calls patient 1 - 3 days post-discharge Med recon and comprehensive medication review Pharmacist updates patient’s physician Makes medication recommendations 80% of patients have at least one discrepancy resolved.

Safe Transitions Involve Many! Safe transitions are best when we maximize a multi-disciplinary approach Group Health: Specialty Medication Reconciliation involves a variety of disciplines Medical Assistant: medication verification Specialist: medication review and hand-off to pharmacist Pharmacist: comprehensive medication reconciliation and communication to patient and appropriate physicians Primary Care Provider: authorize prescriptions and carry out ongoing care of patient’s therapy Group Health’s Multidisciplinary approach to specialty medication reconciliation

Incentivizing Change via Regulatory Process Mandating change and prioritization Technology Adoption

Medication Reconciliation Requirements The Joint Commission Medication Reconciliation Requirements A 6-year journey to improve patient safety 2005 2006 2007 2008 2009 2010 2012 TJC introduces NPSG 8 “Med Rec” required for accreditation NPSG minor revisions NPSG major revisions planned Scoring suspended and some simplification New standards created & released Implementation of new standard

Medication Reconciliation TJC 2011 Medication Reconciliation National Patient Safety Goal #3: “Improve the safety of using medications” NPSG.03.06.01: “Maintain and communicate accurate patient medication information” Applies to: Hospitals, including Critical Access Hospitals Ambulatory Care Office (Ambulatory) Surgery Home Care Long-term Care Behavioral Health TIM

The Patient Protection and Affordable Care Act (H.R. 3590) Value-Based Purchasing (VBP) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) (Section 3001) Core Measures (Section 3001) Healthcare-Associated Infections (HAI) (Section 3001) At Risk: 1% in FY2013 growing annually to 2% in FY2017 (70% Core Measures + HAI and 30% HCAHPS) Medicare Reimbursement TIM Effective Oct. 1, 2012 Reduces Medicare inpatient payments for hospitals with higher than expected risk-adjusted readmission rates for certain conditions. Reduced Medicare payments for every discharge. At Risk: 1% reduction beginning FY2015 At Risk: 1% reduction in FY2013 and will Rise to 3% by FY2015 Hospital Acquired Conditions (HAC) (Section 3008) Readmission Rates (Section 3025) AMI, PNE, HF COPD, CABG, PTCA, etc. 5

Readmissions are… Frequent 18% of all Medicare hospitalizations are 30-day re-hospitalizations Average rates are >20% for certain patient populations Potentially avoidable 76% of Medicare re-hospitalizations were “potentially preventable” Costly $15B annually in Medicare of which $13B may be unnecessary Actionable for improvement Research and quality improvement initiatives have demonstrated >30% reduction of 30-day readmission rates for a variety of populations Medications and medication use are often implicated in unexpected readmissions! http://www.medpac.gov/documents/jun07_entirereport.pdf MedPAC 2007 Report to Congress; Promoting Greater Efficiency in Medicare

Med Reconciliation & Readmissions How much does a hospital readmit cost? $14,500 Our analysis shows that for every 25 patients that receives med recon post- discharge, 1 hospital readmit is prevented. Group Health data. The $14,500 is the approximate cost of a readmission (or an admission). For the 2012 calendar year, the program will save an estimated 1 million dollars 14 day 30 Day Kilcup M, Schultz D, et al. Post-discharge pharmacist medication reconciliation: Impact on readmission rates and financial savings. J Am Pharm Assoc. 2013: Jan/Feb, 53:1.

Opportunities for Pharmacy: Readmissions Preventing Interventions Phase of Care Admission Inpatient Stay Discharge Home Pharmacy Service Provided Perform Admission Assessment Determine factors in admission/readmission Medication history Medication reconciliation Errors of omission (EBM) Adverse drug events (ADE) Medication adherence Medication access Determine post-hospital needs Where will patient likely receive care? Who are caregivers? Barriers to care? Care Optimization Provide effective teaching & enhanced learning Identify barriers to learning Medication management Disease self-management Medication adherence Use “Teach Back” method Provide tools Optimize the medication regimen Initiate indicated medications Discontinue unnecessary or unsafe medications Simplify the medication regimen Prepare for Transition in Care Medication regimen review Medication reconciliation Provide medication list and related information to: Patient/caregiver Physician/medical team Pharmacy/pharmacist Verify appropriate post-discharge care plan Match discharge follow-up to need (readmission risk stratification) Ensure proper information is provided regarding contact information, action plan for care and symptom or AE management Provide Appropriate Post-Discharge Care Contact patient/caregiver Live or virtual visit Patient status and medication review Medication reconciliation Medication adherence ADE surveillance Medication access Med management/ Disease management Communicate to other providers any pertinent medical information or findings

Achieving Medication Safety Goals via Medication Reconciliation Drive Systems (Re)Design and Process Improvement Catalyst Driving Change WPSC Regulatory Organizations Reimbursement Models Maximize Use of Technology Maximize Use of Technology Facilitate Cultural Change

Achieving Medication Safety Goals via Medication Reconciliation Drive Systems (Re)Design and Process Improvement Catalyst Driving Change WPSC Regulatory Organizations Reimbursement Models Maximize Use of Technology Facilitate Cultural Change Facilitate Cultural Change

“My Medicine List” A WPSC Sponsored Project

My Medicine List Heighten Public Awareness Emphasize the need for patients to take an active role in managing their medicines. The initiative’s goal is for every person to maintain an up-to-date list and to share it with his/her health care provider. TIM A campaign intended to build public awareness of the need for patients to take an active role in managing their medicines. Sponsored by the Washington Patient Safety Coalition (WPSC) The initiative’s goal is for every person to maintain an up-to-date list of every medicine he or she is using and to share it with his or her health care provider during each and every visit.

My Medicine List A sample of resources available on the My Medicine List pages of the WPSC web site.

What's in a “Medicines” List Prescription medications Sample medications Vitamins Herbal & Alternative Meds Nutriceuticals & Dietary Supplements Over-the-counter drugs Vaccines Respiratory therapy-related medications Parenteral nutrition Blood derivatives Intravenous solutions (plain or with additives) Diagnostic and contrast agents Radioactive medications Any product designated by the FDA as a drug!

How Can You Help? Remember the 3 As ASK every patient about his or her medicine list at each encounter. ADVISE your patients to carry a list ASSIST your patients with resources & tools Refer your patients to mymedicinelist.org for information and resources What you don’t know about your patients could harm them!

Thank You!