Medication Reconciliation in Home Care - Safer Healthcare Now!

Medication Reconciliation:Understanding the Need‣ Adverse drug events (ADEs) are occurring at analarming rate across all sectors of health care‣ At the core of ADEs is miscommunication andfragmented care processes (Institute of MedicineReport, 2007)‣ To address this, medication reconciliation practicesare being implemented in acute and long term caresettings across Canada. A lot of this work is beingdone through the Safer Health Care Now! (SHN!)campaign intervention on medication reconciliation

Medication Reconciliation:The Drivers for Homecare‣ Body of evidence validating the need for a reduction inhealthcare issues related to medication management‣ Evidence demonstrating significant issues with medicationerrors in home care (Forster et al., 2004; Gray, 1999;Ellenbecker et al., 2008).‣ Changes in accreditation – nationally & internationally andthe growing body of evidence of positive results ofmedication reconciliation (AHRQ, 2005)‣ Lessons learned from the SHN! Campaign interventions inacute and long term care, and the Western Node 2007Medication Reconciliation Collaborative

Medication Reconciliation:Definition(s)‣ Medication Reconciliation is:• a formal process in which healthcareprofessionals partner with patients to ensureaccurate and complete medication informationtransfer at interfaces of care• It involves a systematic ti process for obtaining iamedication history, and using that information tocompare to medication orders in order to identifyand resolve discrepancies. It is designed toprevent potential medication errors and adversedrug events (ISMP, 2008)

Medication Reconciliation:What it Does…‣ Types of errors potentially prevented may include:• Failure to prescribe clinically important homemedications while in the hospital• Incorrect dosage or dosage forms• Missed or duplicated doses resulting from inaccuratemedication records• Failure to clearly specify which home medicationsshould be resumed and / or discontinued at home afterhospital discharge• Duplicate therapy at discharge (result of brand / genericname combinations or hospital formulary substitutions)(ISMP Canada, 2008)

Definition:Medication Reconciliation:Discrepancies• A difference identified between theintent of the prescriber (as determinedfrom sources of information) and whatmedications (prescription and nonprescription) the client is actually taking• Discrepancies can be categorized asintentional or unintentional (ISMPCanada, 2007)• Discrepancies are identified through themedication reconciliation process anddirected to the most responsiblephysician or designate for reconciliation

Medication Reconciliation:The BPMH Tool‣ A Best Possible Medication History (BPMH) -medication history obtained by a clinician whichincludes a thorough history of all regularmedication use (prescribed and non-prescribed),using a number of different sources ofinformation.‣ The BPMH is different and more comprehensivethan a routine medication history, which is oftenquick and comprised of a ‘list’

Interfaces in the MedicationInformation Transfer Process:

Partnering for Client Safety:Three Key PlayersSHN! Medication Reconciliation inHomecare Pilot Project

Aim of the ‘Quest’:Pilot Project Objectives‣ Develop and validate a frameworkto aid homecare providers in theimplementation of medicationreconciliation into their caredelivery processes.• This framework is to take into considerationthe unique challenges of the homecaredelivery setting in Canada.• This is being done by exploring developingand testing medication reconciliationstrategies for implementation in thehomecare setting.

Aim Accomplished Through:‣ Gaining a better understanding of the unique challengesthat exist in home care‣ Exploring the process of obtaining, updating, andcommunicating a complete Best Possible MedicationHistory (BPMH) with home care clients‣ Identifying core processes to aid in the BPMH andidentification of medication errors‣ Testing and modifying a BPMH tool(s) for home care‣ Testing measures which have relevance to monitoring theprocess and outcomes to prevent harm from medicationrelated errors and issues in the home care environment.‣ Developing an information package with tools for thehomecare sector (GSK)

Target Population(Eligibility Criteria)Those clients transferred ed from an acute care setting tothe home care organization for service.

% of eligible clients with a BPMHFactors Impacting Data:completedSample Population = 611 clientsPilot Average = 86.5%‣ High percentage ofmonthly submissions of100100%‣ Volume of referrals80‣ Population density,acuity60‣ Pilot team risk40assessment criteria‣ Number of trained20clinicians‣ Workload0clients w ith a B PMH% of elig ible120AtlanticOntarioWesternPilot Teams

Time to Complete the BPMHPilot Range = 12 to 88 minMedian = 40 minutesFactors Impacting Data:100‣ Chronic diseases‣ Client health literacyHAverag e time (m ins) to c om p lete BP M‣ Clinician60knowledge/training50‣ Process – duplication40of documentation30‣ Interpretation at ofmeasure parameters.90807020100Pilot TeamsAtlanticOntarioWestern

% of eligible clients with BPMHcompleted with at least onediscrepancyPilot Average = 45.2%Factors Impacting Data:‣ Acuity of the clientpopulation‣ Chronic diseases‣ Client health literacy‣ Clinicianknowledge/training‣ Resources availablefor comparisonclients w ith a t least onediscrep ancy% of eligible120100806040200Pilot TeamsAtlanticOntarioWestern

Top Three:Types of Discrepancies1. Client no longer takingmedication as prescribed2. Medication not currentlyprescribed3. Difference in doseFactors Impacting Data:‣ Interpretation of categories‣ Use of a default category‣ Client financial statusIdentifiedd

Risk Points‣ Testimonial:• Elizabeth Carere‣ Lesson Learned• Clients may be at risk for discrepancies whileunder the care of the home care organizationHome Care

Discharge‣ Keeping the ReconciledMedication List updated andaccurate is the best way tobe prepared pfor externaltransfer and / or discharge atany time.‣ If the reconciled medicationlist is continuously updated, itcan be a good source ofinformation for the nextprovider of careHome Care

How to Undertake MedicationReconciliation in Home Care?

Step 1. Identify Client‣ Testimonial:• Kelly Budgell‣ Lesson Learned:• Can be time consuming‣ Accreditation Canada‣ Medication RiskAssessment tool

Step 2: Create the BPMH andIdentify Discrepanciesi‣ Does it work?‣ Testimonials:• Susan Crawford‣ Lessons Learned:• Most tools used currently byhome care organizations are notrobust enough• Education is key to success‣ Tools• Systematic Interview Guide• BPMH Tool

Step 3: Resolve andCommunicate Discrepanciesi‣ Testimonial:• Erna Somfai‣ Lessons Learned:• Home Care clinicians play animportant role in preventingpotential discrepancies frombecoming actual adverseevents related to medications‣ Client Circle of Care

Step 4: Close the MedicationReconciliation iLoop‣ Testimonial:• Nancy Kuto George• Darnell Frostad‣ Lesson Learned• Closing the loop with theclient/family‣ Tools• Client friendly

Who is Involved in MedicationReconciliation i in Home Care?.‣ Testimonial:• Stephanie Moccia‣ Lesson Learned:• The process needs tostart and end with theclient/family and beverified in a mannerthat facilitatesunderstanding

Getting Started Kit:Contents‣ Overview of Medication Reconciliation‣ Medication Reconciliation in Home Care: Who,When, How.‣ Medication Reconciliation as a QualityImprovement initiative• Implementation• Challenges & Strategies• Factors & Strategies• Considerations for Implementation‣ Tools, guides, processes

Getting Started Kit:Contents‣ Medication Reconciliation on Admission:iMeasurement• Identification of Eligible Clients• Core Measures• Optional Measure• Data Collection: baseline & ongoing• Team support

Getting Started Kit:How to Use it!

Next Steps‣ Present GSK at SHN Day‣ Plan for national implementation:• Webinar series / virtual collaborative (6months – June to November 2010)• Goal of 50 home care teams• Targeted education• Targeted support‣ Pilot co – lead organizations to advocatefor support for medication reconciliation inhome care with stakeholders

Contacts:‣ For more information contact:Marg Colquhoun atmcolquhoun@ismp-canada.orgcanada.orgCatherine Butler atcatherine.butler@von.caAnne MacLaurin atAMacLaurin@cpsi-icsp.cai icsp.ca

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