1. Medication Reconciliation in the Community Laying the Foundation!
Marie Owen

2. What is Medication Reconciliation?
Medication Reconciliation is a formal process in which healthcare professionals partner with patients to ensure accurate and complete medication information transfer at interfaces of care
In Home Care this involves getting information from clients and comparing it to orders, medication calendars, labels, vials and other sources of information, resolving discrepancies, communicating and documenting
A process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner or level of care (JCAHO, 2005).
A formal process of obtaining a complete and accurate list of each patient’s current home medications—including name, dosage, frequency, and route—and comparing the physician’s admission, transfer, and/or discharge orders to that list. (ISMP, 2006). In homecare it would be compared to information such as admission referral, medication calendars, Rx bottles, client medication list, etc.

3. Safer Healthcare Now! History of Medication reconciliation
What we’ve learned
Why we are proud
Why we don’t give up!

4. Cross Canada Check-Up 4

6. Medication Reconciliation: What it Does…
Resolves Potential Errors such as:
Failure to continue clinically important home medications while in the hospital
Missed or duplicated doses resulting from inaccurate medication records
Failure to clearly specify which home medications should be resumed and / or discontinued at home after hospital discharge
Duplicate therapy at discharge
Medication reconciliation should occur at interfaces of care (admission, internal transfer, discharge) and at transition between facilities such as acute care centers, community, or long term care where the patient is at high risk for medication discrepancies.

7. What was the problem?
Clients returning home from hospital at risk for falls, ER visits and hospital readmits due to medication adverse events
No standardized approach to medication management
Clients being asked for the same information by multiple care providers
Information not shared between various care and service providers, e.g., Meds Check 7

8. The Need
Required a standardized process for medication management in the community
Sustainable process that generates quality data to track changes / improvements in clients’ outcomes
Responsible for reporting to Central Local Health Integration Network (funders of the project)
Develop a system easy to use
Internally – align with organization’s strategy to provide quality care = safety, science, service 8

10. What can the client/caregiver expect?
Example procedure of a Community Service in Ontario
First visit:
The nurse or pharmacist completes a medication inventory
Best Possible Medication History (BPMH)
Makes recommendations
Preventive medicine is used and prescribed appropriately (e.g., Vitamin D, EC ASA)
Blister pack or dosette system, visual reminders
Increased PSW hours for reminders, OT assessment, referral to a community support agency
Summary completed identifying discrepancies and recommendations; nurse/pharmacist send letter(s) to client’s physicians
Indications are appropriately treated after feedback from physician(s)
Copy is also provided to the service provider. Copies have also been provided to community pharmacist – problematic – no storage
Administration techniques appropriate
Disease exacerbation – knows the plan
When to use Nitroglycerin Spray
SOB – what puffer to have handy
Uncontrolled B.S. when sick 10 10

11. What can the client/caregiver expect?
Example procedure of a Community Service in Ontario
Second visit:
Education to the client/caregiver
Administration techniques appropriate
Provides client/caregiver with medication schedule
A copy of the medication schedule is forwarded to the family physician and service providers
Copy is also provided to the service provider. Copies have also been provided to community pharmacist – problematic – no storage
Administration techniques appropriate
Disease exacerbation – knows the plan
When to use Nitroglycerin Spray
SOB – what puffer to have handy
Uncontrolled B.S. when sick 11 11

12. Examples of Limitations Identified
Example procedure of a Community Service in Ontario
Physical
Cognitive (forget to take medications)
Accessibility (cannot get to pharmacy or family physician)
Adherence (clients may refuse to take medications due to side effects)
Safety
Knowledge gap (many clients do not understand what their medication is, how to take it, why they require it, and what the side effects are)
Storage and Organization 12

13. How have the clients/caregivers benefited?
Example procedure of a Community Service in Ontario
Enables nurse and pharmacist to:
Create a complete and accurate inventory of all medications
Prescribed/over-the-counter/herbal
Assess for Safety, Simplicity and Correctness
Compare the current medications with medications prescribed
Identify any discrepancies or medication related problems
Bring it to the attention of the prescribing physician
Reduction in duplication of assessing for the same medications; sharing of information and involving the primary physician; reducing falls, pain, ED visits. Ultimately spending time with the pharmacist in the comfort of their home without pressures. 13 13

14. Have we made a difference?
Example procedure of a Community Service in Ontario
Population Health
1420 clients received medication reconciliation between April 2010 – March 2011
After MMSS 43% rated ability to self-manage medications as excellent, before MMSS it was 15%
49% improvement in self-management
96% rated ability to self-manage as good or excellent
Only 4% of clients rated fair/poor
Qualitatively – through our satisfaction surveys we received extremely positive responses from clients and caregivers; pre MMSS – had a good understanding of their meds but following MMSS, they identified having an excellent understanding of their meds; as well no one indicated in the survey needing ED services ( may be too early to tell at this time). 14 14

15. Have we made a difference?
Example procedure of a Community Service in Ontario
Population Health (cont’d)
On average, 3-5 discrepancies/medication related problems identified/client
85% of discrepancies resolved
86% of medication related problems resolved
Reduction in .5-1 medication/client
-60% hospital referrals; 40% community referrals
-Average age 80 years
-Taking average meds each
Over 90% of physicians respond to pharmacy requests for clarification in medications 15 15

16. Interfaces in the Medication Information Transfer Process

17. What We’ve Learned
It IS worth the effort - successful teams would not go back to the old way
There can still be a surprising amount of resistance
It requires new processes
It is more complicated than it sounds
BPMH training is required
Patient must be at the centre
The answers are local

18. This Action Series Canada is a leading country!!
Create more experience, successful new approaches and reliable processes in home care
Measure success
Learn from others and spread the learning

19. Question: The Problem Do you have a sense of what the problem is?
Do you believe that there is a problem in the home care environment?
Yes? No?

20. A Medication Reconciliation Allegory/Metaphor!
By Mark Kearney, Pharmacist,
Queensway Carleton Hospital

21. Imagine You come into the hospital wearing size 32 black pants,
a blue shirt,
a black belt
and cowboy boots…

22. You leave the hospital …wearing a green dress A blue shirt … Red shoes
No belt
… and a cowboy hat!

23. What Happened? Discrepancies:
Ordered a cowboy hat instead of cowboy boots
Forgot to reorder your belt
Got the blue shirt right
Replaced the black pants with a red dress
Before After

24. Medication Reconciliation in Home Care
How do we do it?
When do we do it?
Who does it?

25. How?

26. Step One
Identify and target

27. Step Two
Interview
Compare
Identify
Document

28. Step Three
Resolve
Identify
Communicate
Document

29. Step Four
Confirm
Communicate
Verify

30. Question How are you Feeling?

31. Question What step do you feel will be the biggest change to your current process?
Use your pointer

33. Does the process work?
“As a nurse who is always aghast when the client hands me a shoebox full of pill bottles, with no recourse but to just put them on the medication list, I am so thrilled to have a formal method to deal with these medications. Very often this shoebox contains every medication the client has taken for the past 10 years, many of them mixed together or missing labels.
Recently, a client was discharged on parenteral anticoagulant therapy. Without medication reconciliation, he would have continued to take the oral anticoagulant he had been on before his hospital stay. The nurse discovered this issue through the application of medication reconciliation and a potentially dangerous situation was avoided.”
Cheryl Prest RN
Can Care Health Services
Pilot Team Leader

34. When?

35. Who?