Transitions of Care and Medication Reconciliation

Allergies and Intolerances - ________________ - ____________ - Age of ____________ - ___________________ - _________________

- Medication - Reaction - Age of Reaction - Circumstances - Alternatives

Conclusion - Pharmacist can play a unique and important role in helping to ____________ the current system. - ________________ in transitions of care will lead to ____________ patient care and outcomes. - Your goal is to attempt to get the most ____________ list of medications the patient is ____________ taking and _____ they are taking them. Along with any other medication history that is helpful in treating your patient. - A good quality medication __________________ prevents medication ________.

- Pharmacist can play a unique and important role in helping to improve the current system. - Improvements in transitions of care will lead to improved patient care and outcomes. - Your goal is to attempt to get the most accurate list of medications the patient is currently taking and how they are taking them. Along with any other medication history that is helpful in treating your patient. - A good quality medication reconciliation prevents medication errors.

Steps in the med Rec Process 1. Obtain a ___________________________ list 2. ________________ the patient/family 3. Confirm _______________ of interview information 4. Update patients _____________________ 5. _____________________ information to the healthcare team

1. Obtain a baseline medication list 2. Interview the patient/family 3. Confirm accuracy of interview information 4. Update patients medical record 5. Communicate information to the healthcare team

How to Improve transitions Medication Reconciliation - ________ Approach - Pharmacist _____________ - Each ______ of transition Discharge Planning - _______ Approach - _____ Factors for readmission - ____________ care scheduled - _________________ in hand Research - Areas for __________________ - _____ factors - __________________

Medication Reconciliation - Team Approach - Pharmacist involved - Each step of transition Discharge Planning - Team Approach - Risk Factors for readmission - Follow up care scheduled - Medications in hand Research - Areas for improvement - Risk factors - Education

Interview questions _________________ name - Prescription, over-the-counter, herbals _________ _________________, including time of day Recent _____________ - Antibiotic use recently Time of _______ dose Other considerations - Chemotherapy ____________ - Warfarin __________ and last INR check - __________ and ___________ medications

Medication name - Prescription, over-the-counter, herbals Dose Frequency, including time of day Recent changes - Antibiotic use recently Time of last dose Other considerations - Chemotherapy regimen - Warfarin regimen and last INR check - Yearly and weekly medication

Definition - Transition of care _______________ of patient care from one place to another. Examples - ________________ to _________________ - Surgery to patient floor, emergency room to patient floor - Change of ______ - day to night - ______________ to ______________ - hospital discharge to primary care physician - ______________ to _____________ - primary care physician to hospital inpatient - _______________ (cardiology, infection disease, etc.) to Primary Care - _________________ to Specialist (cardiology, infection disease, etc.)

Movement of patient care from one place to another. Examples - Department to Department - Surgery to patient floor, emergency room to patient floor - Change of Shift - day to night - Inpatient to Outpatient - hospital discharge to primary care physician - Outpatient to Inpatient - primary care physician to hospital inpatient - Specialist (cardiology, infection disease, etc.) to Primary Care - Primary Care to Specialist (cardiology, infection disease, etc.)

Definition - Medication reconciliation Formal process - Obtaining the most ____________ and ___________ list of a patient's medication - Comparing medication orders to ____ of the medications the patient is currently taking and resolving any ___________________ Goal - To avoid medication ________ including omissions, duplications, incorrect dosing or timing, and drug interactions

Formal process - Obtaining the most complete and accurate list of a patient's medication - Comparing medication orders to ALL of the medications the patient is currently taking and resolving any discrepancies Goal - To avoid medication errors including omissions, duplications, incorrect dosing or timing, and drug interactions

Interview Patient or Family Member How to start: Hi John Smith, My name is Jen. I am a pharmacist here at Concord Hospital. I have a few questions for you about the medications you take at home and your allergies. Is now an ________________________________ about this?

How to start: Hi John Smith, My name is Jen. I am a pharmacist here at Concord Hospital. I have a few questions for you about the medications you take at home and your allergies. Is now an OK time to talk with you about this?

Communication with Healthcare team Verbal communication - Confirm ______ of a specific medication - Discussion around any ________ or ____________ - Report process _____________ Written communication Published note in the patient chart detailing out any ____________________________ that might be helpful to the team. - Any recent _____________ in the patient's medications - ____________________ that are unresolved - How you completed the medication _____________________

Verbal communication - Confirm dose of a specific medication - Discussion around any issues or concerns - Report process complete Written communication Published note in the patient chart detailing out any additional information that might be helpful to the team. - Any recent changes in the patient's medications - Discrepancies that are unresolved - How you completed the medication reconciliation

Pharmacist Role _______________ - Patients, healthcare provider Patient _________________ - Intervention, documentation Medication ___________ - Clinical skills, medication knowledge

Educator - Patients, healthcare provider Patient Advocate - Intervention, documentation Medication expert - Clinical skills, medication knowledge

Medication history Obtain all necessary information to help the healthcare team make the best ___________ for the patient. This includes: Medications patient is taking at _______ and _____ they are taking them Recent changes to the patient's medications - Started a _____ medication - Changes in medication ________ - _________________ of a medication - This includes recently finished ______________ Additional information about medications - __________ information for healthcare team that manage complex regimens (e.g. chemotherapy or warfarin) Medication _________ history

Obtain all necessary information to help the healthcare team make the best decision for the patient. This includes: Medications patient is taking at home and how they are taking them Recent changes to the patient's medications - Started a new medication - Changes in medication doses - Discontinuation of a medication - This includes recently finished antibiotics Additional information about medications - Contact information for healthcare team that manage complex regimens (e.g. chemotherapy or warfarin) Medication allergy history

Why are we talking about transitions of care? __________________ medication errors impact 7 million patients in the US annually. - 400,000 preventable deaths - 1.5 million patients with serious harm - _______________ hospitalizations and/or hospital readmission -> increased healthcare costs Annual cost of these medication errors is about $___ billion dollars a year. About 30% of hospitalized patients have a ______________ on their discharge medication list when they leave the hospital. - This leads to adverse drug reactions, drug-drug interactions, and health risks to the patients. - This is a _________________ medication error

Preventable medication errors impact 7 million patients in the US annually. - 400,000 preventable deaths - 1.5 million patients with serious harm - Prolonged hospitalizations and/or hospital readmission -> increased healthcare costs Annual cost of these medication errors is about $21 billion dollars a year. About 30% of hospitalized patients have a discrepancy on their discharge medication list when they leave the hospital. - This leads to adverse drug reactions, drug-drug interactions, and health risks to the patients. - This is a preventable medication error

Points of Concern for Pharmacists __________________ ____________ drug reactions Medication _________ - Omission, duplication, drug-drug interactions ______________________ between healthcare providers Follow up and __________________ of care _______________ providers prescribing medication

Readmissions Adverse drug reactions Medication errors - Omission, duplication, drug-drug interactions Communication between healthcare providers Follow up and coordination of care Multiple providers prescribing medication

Common problems ________________ of information - Patients, family members, patient chart ______________________ of information to patients or providers Pharmacies and doctors offices are _______, __________, or difficult to connect with Methadone Clinics - Require a signed _________ form from your patient - This is NOT a __________ protected relationship between providers so more challenging to be able to get information for your patient.

Reliability of information - Patients, family members, patient chart Communication of information to patients or providers Pharmacies and doctors offices are busy, closed, or difficult to connect with Methadone Clinics - Require a signed consent form from your patient - This is NOT a HIPAA protected relationship between providers so more challenging to be able to get information for your patient.

Medication List Starting points: From scratch - ___________, family member, _____________, doctor's office Previous admission - Medication ___________________ at admission - ______________ summary ___________ medication record Prescription ____________ ______________ formulated medication list ___________________ medication list _____________________ medication record ______________________ processing software

Starting points: From scratch - Patient, family member, pharmacy, doctor's office Previous admission - Medication reconciliation at admission - Discharge summary Global medication record Prescription bottles Patient formulated medication list Primary care medication list Nursing home medication record Insurance claim processing software