Medication Reconciliation& Medication Therapy Management

Discharge Medication List

-A medication list given after a patient is discharged from a facility (i.e. hospital, rehab, or nursing home) -Most discharge lists provide a list of medications that have: * New Medications * Stopped Medications * Continued Medications * Changed Medications -NOTE: This list may not include home medications that weren't continued during the stay or weren't reported initially in the hospital records

Comprehensive Medication Review (CMR)

-A systematic process to achieve the following goals: * Collect patient-specific information * Assess medication therapies to identify medication-related problems * Develop a prioritized list of medication-related problems * Create a plan to resolve them with the patient, caregiver, and prescriber -Involves an interactive person-to-person or telehealth medication review and consultation * Conducted in real time between the patient or other authorized individual -Designed to improve patients' knowledge of their prescriptions, OTCs, herbal therapies, along with dietary supplements -Identifies and addresses problems or concerns that patients may have -Empowers patients to manage their medications and health conditions

The Joint Commission (TJC)

-Accurate and complete reconciliation of medications across the continuum of care is a National Patient Safety Goal since 2005 -Recommends that medication histories be reviewed and compared to current regimens on admission, transfer, and discharge

Agency for Healthcare Research and Quality

-Devised a medication reconciliation toolkit

Medication Discrepancy Assessment

-Each medication discrepancy should have a mini assessment & plan -Consider writing a 3-bullet point note under each discrepancy: * First line may talk about the current issue * Second line may provide an assessment that may discuss previous history, lab reports, or symptomatology * Third line should discuss your course of action or plan of how to fix the discrepancy

Performing a Preliminary CMR

-Gather a medication list -Determine disease states -Identify patients' healthcare providers -Identify potential medication-related problems

Example of a Patient-Reported List

-Glipizide 10mg daily -Metformin 600 mg twice daily -Blood pressure medicine 25 mg daily -Blue pill once daily -Dr. Ron's Organic & Wildcrafted Heart Tonic daily

Why Do Errors Occur?

-Medication reconciliation is a complex process -It involves diligent work, active communication between providers and patient, and critical thinking when discrepancies occur -Several reasons why these errors may occur is due to: * Lack of understanding with medications * Forgetting to document medications * Not asking about OTC/vitamins/herbals * Not addressing any medication discrepancies noted * Poor communication between providers

Take Home Points of Med recs

-Medication reconciliation is a complex process that requires time and patience -Multiple medication lists may be available - use one as your "reference list" -Refill histories from community pharmacies provide an idea if patient is really taking a medication or not -Utilizing the 6 D's to a med rec will help ensure accurate medication lists

Institute for Healthcare Improvement (IHI)

-Medication reconciliation remains the top targeted intervention to prevent adverse drug events -Poor communication of medical information during the transition of care is responsible for as many as 50% of all medication errors that occur in the hospital and 20% of adverse drug events

Factors That Can Affect the Choices Made During a CMR

-Patient -Payers -Family/caregiver -Prescriber -Individual conducting CMR -Employer expectations

Medication Reconciliation Definition Know as Med Rec

A process involved with comparing multiple medication lists to each other in order to compile the best updated medication list for a patient Also involves rectifying medication-related issues when drug-therapy problems or discrepancies are identified

Medication Discrepancy Assessment: Example

Vitamin D3 2000 units PO daily Issue: Patient states she's not taking this medication Assessment: Last vitamin D level was low at 7 ng/mL on 6/8/20 Plan: Recommend to PCP to draw new lab and if still low patient will restart vitamin D

-Nurses, pharmacists, pharmacy students, pharmacy technicians, physicians, medical assistants can perform a med rec -Clinical Study (Tong, et al): * 832 patients received some form of medication reconciliation at discharge * In the group that received a standard discharge summary - 265 patients out of 431 had at least 1 documented error (61.5%) * In the group that had a med rec completed by a pharmacist - 60 patients out of 401 had at least 1 document error (15%) " Pharmacists are important to perform med rec du to medication experts and have insight about target questions to ask patients when they review their chart for the medical history."

Who Should Perform a Med Rec?

Utilize the Medication Bottle

-Have the patient bring in all of their medication bottles -From the label you can see: * Medication information (name, strength, directions, etc) * Prescriber * Fill date -The fill date can help determine if a patient is non-adherent -If it was last filled several months ago → likely non-adherent -Can also count number of pills in the bottle * If many are still remaining → likely non-adherent

Settings Where a Med Rec is Performed

-Hospital *Emergency department *Admission *Discharge -Primary care physician's office -Specialist physician's office -Nursing home -Community pharmacy

Medication Therapy Management

-Identifies medication-related problems -Helps patients understand all of their medications especially at any transition of care as well as at discharge when they are faced with how and when to take their medications on their own

Probing for More Information

-If you suspect a medication list is not accurate for any reason you should probe for more information * i.e. Incorrect doses on list, duplicate therapy, unusual frequencies, etc. -Assess how the patient is actually taking medications * This is important for PRN medications * Look for phrases such as: •"I'm supposed to take it..." •"The bottle says..." •"My doctor says..." -Be sure to look for warning signs of non-adherence * e.g. Many pills remaining in bottles * e.g. Late to refill or has not refilled at all -Just because a list says the patient is to take a medication doesn't mean the patient is actually taking it!

Common Medication Reconciliation Errors

-Incorrect Dosing * Patient takes clozapine 200 mg qAM and 50 mg qPM oDischarged with 200 mg tablets only -Wrong Drug * Hydroxyzine pamoate vs. hydroxyzine HCl * Metoprolol succinate vs. metoprolol tartrate -Incorrect Formulation * Depakote ER vs. DR Suspension vs. solution -Incorrect Directions * Rifampin 300 mg - 1 tab PO BID oShould really read: 2 tablets PO daily -Drug Omissions * Forgetting to include vitamins, supplements, and minerals

Community Pharmacy Med Rec

-List typically only contains medications filled at that particular pharmacy or chain of pharmacies -May be most up-to-date for recent fills -May contain refills for medications patient is no longer taking * Pharmacies rarely get stop orders -OTC medications typically are not on list -Newer systems may allow for entry of historical meds

Prescriber Communication

-May take place in many formats (fax, email, letter, phone call) -MTM pharmacist should determine whether an issue is urgent (requires a phone call) or non-urgent (fax, email, letter) * Examples of urgent situations: •Patient has excessive bleeding from warfarin •Severe drug interaction * Examples of non-urgent situations: •Patient is missing a particular medication for a particular disease state •Potential cost-saving opportunity has been identified -Communication with physicians should be concise yet thorough Provide the physician with specific recommendations

Last Few Pointers: Med recs

-Med recs can get very overwhelming when many discrepancies are found -Just remember to take NOTES on each discrepancy -Prioritize the issue from most important to least important -Be sure to identify the prescribing doctor first to discuss the discrepancy issue

Medication reconciliation

-Occurs at points of transition -May identify medication-related problems -Goal - capture an accurate medication list for the patient and compare current medications to the drug regimen being considered at the next location

Follow-Up

-Required at least quarterly for Medicare Part D patients -May include a phone call, personal interview, or a review of the patient's current health record and prescription refill history -MTM pharmacist should review and reassess actions that were determined for pertinent medication-related issues during the CMR -New medication-related problems arising from newly added or discontinued medication may also be identified * MTM pharmacist should document these and take appropriate action

Completing a Medication Reconciliation

-Select one medication list as the "reference list" -All other medication lists are compared to reference list -Group all medications into different "classifications" based on your findings such as: 1. Medications the patient takes but are NOT on my reference list 2. Medications the patient is NOT taking at all 3. Medications with discrepancy found in directions, route, or frequency

Personal Medication List (PML)

-Should contain all prescription medications, OTCs, and medical supplies -The following information should be included for each item of the PML: * Medication name * Dose of medication * Indication * Prescriber name * Directions for use * Special instructions -Other information that may be included on the PML can include date of birth, phone number, emergency contact information, primary care physician and contact information, pharmacy name and contact information, and allergies

Helpful Pointers

-Take your time!!! -Prioritize * Identify which drug-related problems are urgent vs. which can wait -Choose one list as your primary list (compare this to all others) -Organize: * Make a list of all medication discrepancies you found * Write down how you are going to resolve each discrepancy * Do not ignore any discrepancies you find - all should be addressed!

Hospital Admission Record

-The patient's current medications are documented in the electronic health record (EHR) -List is typically patient/caregiver reported * Should be verified with another list! * Verify with patient's community pharmacy! -The admitting physician reviews the home med list and decides to either continue or discontinue each home medication during hospital stay

Medication Action Plan (MAP)

-The patient's guide regarding any potential medication-related problems, disease-related problems, or general counseling provided by the MTM provider during the CMR encounter -Should only include information and goals that are within the pharmacist's scope of practice, not issues that require prescriber approval or guidance -The most important counseling points should be prioritized -Should include appropriate word choice, spelling, and grammar to ensure that the information is clear and useful for the patient -The information must be an appropriate reading level for the patient

Conducting the CMR

-Time management and efficiency are key -Informed consent must be obtained -Document medication usage -Collect health-related details * Adherence * Indications and therapeutic goals * Lifestyle * Safety * Effectiveness

After the CMR - Care Plan

-Without documentation, there will not be a complete record of the patient interaction and rationalization for the decision-making processes -Thorough documentation allows for continuity of care and is usually required for reimbursement -Any identified medication-related issues during the CMR should be documented * Some medication-related issues identified during the pre-CMR will be nullified * Other medication-related problems may have been clarified as being clinically significant * Newly discovered medication-related issues may become evident -The remaining clinically relevant medication-related issues should be prioritized, and the MTM provider should determine which require immediate action -Once the issues have been prioritized and the method of intervention identified, it is time to document the plan of action and follow-up for each of these issues in the care plan

The Six D's to a Medication Reconciliation

1. Drug Name •Spell name correctly! •Determine what the drug is indicated for 2. Dosage Form •Tablet, capsule, solution, suspension, or injection •Immediate release vs. extended release vs. delayed release 3. Dose •In milligrams, grams, units, mg/dL, mg/ml •Example: metformin 1 g, sitagliptin 100 mg 4. Directions •By mouth vs. topically vs. intravenously vs. subQ •Once daily vs. twice daily vs. every 4-6 hours 5. Date Last Filled •How long ago was it last filled and for what day-supply? •Date helps to see if patient is still actually taking the drug 6. Doctor (prescribing medication) •Which doctor prescribed it? PCP or specialist? •Who should you discuss information with?

Governing Bodies

Institute for Healthcare Improvement (IHI) The Joint Commission Agency for Healthcare Research and Quality

Med Rec vs. MTM

Medication reconciliation -Occurs at points of transition -May identify medication-related problems -Goal - capture an accurate medication list for the patient and compare current medications to the drug regimen being considered at the next location Medication Therapy Management -Identifies medication-related problems -Helps patients understand all of their medications especially at any transition of care as well as at discharge when they are faced with how and when to take their medications on their own

Purpose of a Med Rec

Serves to minimize medication errors such as: -Therapeutic duplications -Unintended Omissions -Incorrect use of medications -Drug-drug Interactions -Drug-disease contraindications The main parts of a "med rec" are to: 1. Compile/update patient's medication list 2. Rectify and resolve discrepancies & drug-related problems

Medication Therapy Management (MTM)

Service that is reimbursed through Medicare Part D with specifically defined elements: 1. Comprehensive medication review (CMR) 2. Personal medication list (PML) * A record of all the patient's medications (including over-the-counter medications, herbals, and dietary supplements) 3. Medication action plan (MAP) * A patient-centered document that empowers the patient to take personal action and track their progress of self-management 4. Intervention and referral to other healthcare professionals as appropriate 5. Documentation and follow-up

-Discharge hospital records -Hospital medication orders -Nursing home medication records -Refill history from pharmacy → Refill history can help determine adherence to medications -Personal medication lists from patients -Transfer orders -Insurance company claims -Patient's pill bottles -From patient's own recall → Several issues can occur using this alone

What Documents Should Be Utilized When Performing a Medication Reconciliation?

Comprehensive Medication Review (CMR) flowchart

What is depicted in the image?

Example of Medication Discrepancy List

What is depicted in the image?

-Any point the patient is transitioned from one place to another -This is considered "transitions of care" -Examples include: *Hospital admissions *Hospital discharge *Following-up with primary care provider (PCP) AFTER being discharged *New to a specialty office *New to an outpatient pharmacy *Switching from one PCP to another

When Should a Med Rec Be Performed?