1. Medication Reconciliation in Home Care: Partnering with Patients for Safety
Debbie Conrad RN, VON Canada and Olavo Fernandes PharmD, ISMP Canada
SHN ! Medication Reconciliation Home Care Pilot Oct 14, 2008

2. Creating the most “up to date” medication record (best possible medication history)
Compare:
Medication Information from all other sources
Patient and Family Interview
Examples:
Medication vial inspection
Referral record
Community pharmacy
Hospital Discharge Summary
“medication discrepancies that require clarification”
document
“up to date” medication record (BPMH)
Review and follow
up where indicated

3. Process For Identifying “Medication Discrepancies That Require Clarification” In Home Care
Creating the most “up to date” medication record (best possible medication history)
Compare :
Patient / Family Interview ( a systematic and comprehensive, medication history interview- representation/ snapshot in time of what medication the client is actually taking)
Vs.
all other available sources of medication information (home care referral records, inspection of medication vials/ samples, community pharmacy information, hospital medication discharge summaries, unfilled prescriptions etc)
IDENTIFY: Medication Discrepancies That Genuinely Require Clarification”

4. • Herbals/ Non-prescription
Process For Identifying “Medication Discrepancies That Require Clarification” In Home Care
• Note process must include patient/ family medication history interview
• Reconciliation process allows for clinician professional judgment to discern which “discrepancies genuinely require clarification “
• Herbals/ Non-prescription
(over-the counter drugs)- will not classify as a discrepancy requiring clarification – unless prescribed by physician (or other prescriber)

5. WHO HAS THE BEST MED LIST ?
Patient Interview
Labels on Rx Vials
Medication Lists
Family MD
Patient’s Actual Medication Use
Medical chart
Medication wallet
cards
Community pharmacist
Patient’s Medication Regimen Prescribed 
What is the “truth”?
Y. Kwan BScPhm

6. What is a Best Possible Medication History ?
Creating the most “up to date” medication record (best possible medication history)
A medication history obtained by a clinician which includes a thorough history of regular medication use (prescription and nonprescription)
Uses information from multiple sources: medication vials, hospital discharge summary, patient or caregiver interview, inspection of prescription vials, community pharmacy follow-up or current med list printed by community pharmacy
What about a just a “quality” patient interview?

7. Medication History: Information Sources include…..
Provincial drug data base
Patient interviews
Hospital discharge summary
MD chart notes
Standardized forms
Family MD records
Inspection of Medication vials
Review of community pharmacy records
Review of previous home care records

10. Common Challenges & Solutions
Communication barriers
Non – English/ French speaking patients
Level of consciousness/ cognitive impairment – post op/ acutely ill
Solution: family members , interpreters, community pharmacy
Patient understanding of need to obtain an accurate medication history
Solution: proactively explain importance, empower patient to actively participate

11. Common Challenges & Solutions
Poor perception of what is a medication?
Patients may not commonly list : OTCs, herbals, vitamins, non-traditional , street drugs
Solution: effective prompting/ follow/ up questions
Time/ Resources needed for a BPMH
Solution: Active Preparation: review other sources/ primary medication histories prior to interview to streamline process/ anticipate discrepancies
Medication Use  Medication prescribed
Solution: Focus on “medication use”
Solution: Seek clarification : community pharmacy, primary care physicians, family

12. Getting Organized! What is our commitment to the project?
Review the letter of commitment with the team
Review the Introduction package
Confirm your team
Letter of Commitment: The commitment of the team to the project is listed in the letter. Review it with all team members.
Introduction Package: The will be to you soon. The finishing touches have been completed and will be ready for dissemination soon.
Confirm your team: The sooner the better…assign tasks
All of these will be used as reference when you are completing your team charter

13. First Steps Team Charter
Understand the definitions and terminology of the project
Understand the Medication Reconciliation Process
Understand your policies around charting and Med Reconciliation
Team Charter
Access/enlist the support of your local manager/director of quality
Review the background paper on Medication Reconciliation in Home Care
Team Charter:
Purpose of the project
Scope and Boundaries
Aim Statements
Measures to be tracked timelines and reporting
Ideas for change
This is a live document which is managed as the team moves through the project. It should include timelines for changes and evaluation
As we move through this presentation it will give you information for your team charter
We will have some samples to send to you to help you with it.
Education:
Understand the definitions & terminology of the project, medication reconciliation process, agency policies & procedures,
Understand the case for medication reconciliation in the home

14. Identify your Target Population
Clients newly discharged from acute care and have at least one prescribed medication
Client assigned to Trained Service Providers
Clients with a positive Med RAT Score
Project Level Criteria
Newly discharged from an acute care facility ( new client , or existing client discharged from acute care facility)
At least one prescribed medication
Pilot Team Level Criteria
All referrals assigned to the trained service providers as determined by the pilot team
Service Provider Level Criteria
Criteria for the “Target Population” is finalized by the service provider using the Medication Risk Assessment Tool
The risk assessment tool will be developed by the pilot team and carried by the trained service providers at all times
Medication Risk Assessment Tool
This tool will be developed by the team. The questions will refine the target population directed by the scope and boundaries set out in the Team Charter
Example:
Does the client have 4 or more prescribed medication?
Is the client on Warfarin?
Does the client have any identified cognitive issues?

15. Who Will Identify the Target Population?
The designated trained service provider

16. Selecting Your Sample
You have identified your client as being with in your target population
The service provider will decide whether it is appropriate to continue with the BPMH
Remember, they all need it but can you do it for all….So pick and choose

17. Factors Effecting your decision on Sample Selection
Is the client able to participate in the interview process for BPMH?
Is family available?
Is the situation appropriate to carry out the interview?
Do you have the time?
Is it feasible to return and complete it another visit?

18. Sample Size Dependent on referral volume
Dependent on your target population size
Dependent on the number of trained service providers
5 point baseline
SUGGESTION
Number of trained Service providers:
Three trained service providers doing one to two BPMH’s per week will give you a sample size of 12 to 24 per month.
Three trained service providers may give you good coverage over holidays, vacation weekends etc.
But bottom line you decide being aware that the bottom line in sample size is 5. Anything less will not generate credible measures.
The suggested aim of sample size is 10 to 20 clients per month in total, depending on the size of the agency

19. The Medication Reconciliation Process
Identify eligible client
Decision include as sample?
Interview client/family
Gather information from all sources
Record Meds in BPMH form
Fax to Dr
Return to client as most up to date medication record signed by physician

20. Challenges to Medication Reconciliation Process in Home Care
Complexity of Home Care Systems, Multiple interface points
Chart in the home
Physician inclusion/compliance
Financial/Time Restraints
Paradigm shift
Other
How are we going to manage these challenges?
Keep it as simple as possible in our complex world. The fewer the steps the less change for variances and obstacles popping up.
We have multiple interface points within our own organization beyond transfer to outside world.
Chart in the home.
How are we going to manage the transfer of information to the physician for review and confirmation, while still keeping the information in the home wit the client? Remember, keep it simple!
Think about carbon copying, the BPMH, tools, consider the cost versus time to transcribe information to fax to physician.
We have little control over the physicians, but we can do everything in our power to set the process up for success.
Use a standard cover page with a brief introduction of the process asking for review and send back asap.
Smaller communities you may want to set up a meeting or teleconference with the physicians and let them know what the project is about
As with most people, they will want to know what is in it for them….
well they will have an accurate up to date list of client meds….reduce adverse events…compliance better.
Time up front as opposed to time through course of service…already is a process in place….service providers will tell you…all the time they spend chasing down docs….looking in closets will this is reworking the process to increase efficiency.
Different way of thinking…engaging all across the continuum

21. Data Collection
What data needs to be collected to satisfy the measures to be monitored?
The size of the target population
The size of the sample population
The number of BPMH completed
The time it takes to complete the BPMH
The number and coding of discrepancies

22. Suggestions for Data Collection: Keep it Simple!
Use your Med RAT as a collection tool for your target population.
Submit all of your positive Med Rats to your designated person for recording on a master sheet in your office
Keep it as simple as possible
Use the tools you already have
Use your MedRAT for confirmation of your target population
Fax or deliver all your positive MedRat’s to the office

23. Data Collection: Suggestions
Record your data on your BPMH form.
When faxing the BPMH to the physician for review, also fax a copy to the designated person to be recorded on the master sheet.

24. Data Submission: Monthly
Electonic Data Collection Tools
Will be made available for you.
One tool for each measurement:
Transfer data to these tools for submission to the CMT this is usually done by the team leader. This is something you should outline in your charter so there is clarity of rolls and tasks
Final process for submission is pending

25. Identify Factors Which Impact Data Collection
Low /high volume of referrals
Number of trained Service Providers
Implementation of change: tools process
Weather
Vacation, Holidays, Weekends
YOU SHOULD RECORD ANY FACTORS BY TYPE AND DATE; THIS IS IMPORTANT WHEN YOU ANALYSIS YOUR DATA ONCE IT IS RETURNED TO YOU FROM CMT: YOU WILL BE ABLE TO SUBSTANTIAL DIPS AND SURGES IN YOUR RUNNING CHARTS
Volume of Referrals: no control over this but the trained service provider can be proactive and alert the scheduler to assign her new admissions if the volume is low. And Just do as much sampling as possible
Lack of trained staff: If your target population does not reflect your volume of referrals then perhaps you might want to entertain the idea of increasing your complement of trained service providers. Or perhaps you have a service provider gone on vacation or off sick…need enough staff to balance this
Implementation of change: expect completion time to be slower until the service provider becomes more adapt at using the tool and process.
Vacation: Well we need to continue tracking regardless but sampling may reduce not because of a lack of trained service providers but because of time restraints

26. Data Collection Tools
Medication Risk Assessment Tool MedRAT to identify your target population
Tool for delivering the balance of data from the home to your master sheet
Master sheet
LETS REVIEW THE TOOLS: REMEMBER KEEP IT SIMPLE: YOUR MIGHT WANT TO START WITH THREE TOOLS FOR COLLECTION
MedRAT:
Use this tool to identify your target population. Submit all your positive RAT scores to the central office for recording in the master data collection tool. This tool should include the client’s name and health card number so it can be recorded on the master sheet
BPMH FORM:
Our colleagues out west used the BPMH form as a collection tool as well. Lets learn from them and adopt this approach where/when possible. The balance of the data needed can be extracted from this form if there is a place for it. However when you are first starting you may be using the tools you currently have so you may need to develop a tool in the mean time until you start implementing changes in you BPMH tools
Monthly Master sheet:
This is where you are going to collect all your data. Record all the names for clients who have positive RAT scores.
As the BPMHs come in look for the client name and complete the balance of the data collection.
You may notice at times that the RAT and the BPMH may arrive together. Some BPMH may be delayed and some may not arrive at all which is an indication that the client was not selected as a sample.

27. SHN! Home Care Pilot Measures
Percentage of Eligible Clients with a Best Possible Medication History (BPMH) conducted by a Home Care clinician
Time to complete Best Possible Medication History (BPMH) in Home Care
Percentage of Eligible clients with at least one discrepancy that requires clarification
Classification or characterization of actual discrepancies that require clarification
Also serves as a communication and documentation tool to other clinicians

28. Get Started! Get your tracking tools ready
Start your baseline data collection
Allow your normal referral process and service provider assignment to occur
Your designated service providers will take it from there.
Apply the medication reconciliation process using your present tools and processes
Identify opportunities for change!