5/21/2012. JCAHO National Patient Safety Goal: Maintain and communicate accurate patient medication information.

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1 Is 3 rd leading cause of patient harm Medical errors - 8 th leading cause of death in the US Each year in the US, est. 450, preventable med-related adverse events occur 20% of patients have complications within 3 weeks of DC from hospital Adverse Drug events are most common problem Medication errors are the most common type of medical error and lead to: Disease exacerbation Increase in re-hospitalization Higher utilization of acute and outpatient care 1

2 The comprehensive assessment must: Include a review of all meds the patient is currently using Identify any potential adverse effects and drug reactions including: Ineffective drug therapy Significant side effects Significant drug therapy Duplicate drug therapy Noncompliance with drug therapy JCAHO National Patient Safety Goal: Maintain and communicate accurate patient medication information. Rationale: Medication discrepancies can affect medication outcomes. Medication reconciliation is intended to identify and resolve discrepancies. Elements of Performance: Obtain and/or update information on the medications the patient is currently taking. This information is documented in a list or other format this is useful to those who manage medications. Define the types of medication information (for example, name, dose, route, frequency, purpose) to be collected in different settings and patient circumstances. Compare the medication information the patient is currently taking with the medications ordered for the patient in order to identify and resolve discrepancies. 2

3 Elements of Performance(continued): Provide the patient(or family as needed) with written information on the medications the patient should be taking when he or she leaves the organization s care(for example, name, dose,route,frequency,purpose). Explain the importance of managing medication information to the patient. M2000 Drug Regimen Review M2002 Med Follow Up M2004 Med Intervention M2010 Pt/Cg High Risk Drug Education M2015 Pt/Cg Drug Education Intervention M2020 Management of Oral Meds M2030 Management of Injectable Meds M2040 Prior Med Management 3

4 Management of Oral Medications: Patient s current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. (NOTE: This refers to ability, not compliance or willingness.) 0 Able to independently take the correct oral medications and proper dosages at the correct times 1 Able to take medications at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart 2 Able to take medications at the correct times if given reminders by another person at the appropriate times 3 Unable to take medications unless administered by someone else If the patient does not have her prescribed medications in the home because she cannot afford them and she does not plan on getting them, what is the most appropriate response for M2020? When answering this question you are reporting the patient s ability to take all meds reliably and safely at all times on the day of the assessment. If the patient did not take her medications on the day of assessment because they were not present in the home, you CANNOT make assumptions about a patient s ability to take medications she doesn t have. If the meds were not in the home, you would not be able to determine if she could take each med at the correct time and dose. The patient s status would be reported as 3-Unable to take medications unless administered by another person. 4

5 The process of identifying the most accurate list of all medications a patient is actually taking including name, dosage, frequency, and route. The information is then used to determine which medications the patient should be taking per physician orders. *Adapted from CHAMP (Collaboration for Home Care Advances in Management and Practice) and from the Institute for Healthcare Improvement Medication Reconciliation Process Verify- Collect an accurate medication list COLLECT and VIEW all the medication bottles including OTC, herbal products, dietary supplements and vitamins Ensure the patient has an accurate medication i list and verify against physician orders Clarify- Clarify any questions about drug/dose/frequency/route Reconcile- Communicate with physician about any identified medication questions or concerns 5

6 Admission Transfer to another facility or provider Discharge After medical appointments Any new or changed medication order from physician At SOC, did someone TALK with you about all of your medications At SOC, did someone ask to SEE all of your medications In the last 2 months: did you have any new or changed medications? did someone talk with you about the purpose of new or changed medications did someone talk with about when to take these medications did someone talk with about the side effects of these medications 6

7 HHVNA s Acute Care Hospitalization (ACH) rate is higher than the national average according to OCS data Sept (cumulative score) - HHVNA: 30% - National: 29% 7

8 96% of pts. had 10 or more medications 59% of pts. Had 20 or more medications One patient had 42 different medications 59% of pts. had admitting primary or secondary diagnosis of CHF or COPD 23% of pts. Had re-hospitalization diagnosis of CHF or COPD 44% of pts. Re-hospitalized within 6 days of SOC/ROC 96% of patients re-hospitalized within 4 days of last clinician visit 89% of pts. were compliant with POC/meds 78% of pts. predominantly saw primary clinician 74% pts. had MD appt within 2 weeks of SOC 22% of pts. called agency before hospitalization 45% of pts. were sent to ED by MD 8

9 Educate all staff at Team meetings High Risk Drug List Definition/Process of Medication Reconciliation Oasis medication questions NEW Medication Teaching Sheet NEW Tip sheet- Things to Say / Things to Do Zone Tool Teach Back Method Best Practices STAR Telehealth Drug Classification Anticoagulants Examples of Drugs Arixtra (Fondaparinux Sodium) ASA Coumadin (Warfarin) Heparin Lovenox (Enoxaparin Sodium) NSAIDS Plavix ( Clopidogrel Bisulfate) Anticonvulsants Dilantin (Phenytoin Sodium) Phenobarbital Tegretol (Carbamazepine) Antidepressants Elavil (Amytriptyline Pamoate) Prozac (Fluoxetine Hydrochloride) Zoloft (Sertraline Hydrochloride) Antipsychotics Lithium Klonopin (Clonazepam) Risperdal (Risperidone) Zyprexa (Olanzapine) Cardiovascular Corticosteroids Hypoglycemics Opioids Sedatives Cardiazem (Diltiazem Hydrochloride) Isordil (Isosorbide Dinitrate) Lanoxin (Digoxin) Lasix (Furosamide) Lopressor (Metoprolol Tartrate) Norvasc (Amlodipine Besylate) Tenormin (Atenolol) Decadron (Dexamethasone) Medrol (Methylpresnisolone) Prednisone Insulins Glucophage (Metformin Hydrochloride) Glucotrol (Glipizide) Codeine Fentanyl Methadone Morphine Oxycodone Ambien (Zolpidem Tartrate) Ativan (Lorazepam) Buspar (Buspirone Hydrochloride) Restoril (Temazepam) Valium (Diazepam) Xanax (Alprazolam) 9

10 Things to SAY Agency Name: Home Health VNA Employee Name and Title Explain things in an Easy to Understand way Arrive at what time (within a 2 hr range) g) Home Safety I'm looking around for any safety concerns Pain Gently (change your dressing, Bend your knee.) Meds (prescription and over the counter) 1. See them 2. Purpose of taking 3. When to take 4. Side Effects of meds 5. Any New meds Clearly address knowledge of case know what all disciplines are doing! Things to Do Treat patient with Courtesy and Respect Check home for Safety Check chart before going into patients so you are informed of care Arrive within the range you said you would or CALL them to and tell them you will be late Listen Carefully be attentive CHF Zones for Management Your Current Weight: GREEN ZONE: ALL CLEAR GREEN ZONE MEANS: No shortness of breath No swelling No weight gain No chest pain No decrease in your ability to maintain your activity level YELLOW ZONE: CAUTION Weight gain of 2 or more pounds in 24 hours or 5 lbs in 7 days Increased cough Increased swelling Increase in shortness of breath with activity Increase in the number of pillows need Anything else unusual that bothers you all Home Health VNA if you are oing into the YELLOW zone: RED ZONE: MEDICAL ALERT Unrelieved shortness of breath: shortness of breath at rest Wheezing or chest tightness at rest that is not relieved by medication Chest pain not relieved by medication Need to sit in a chair to sleep (if this is a new symptom for you) Weight gain or loss of more than 5 pounds in 2 days Confusion Your symptoms are under control Continue taking your medications as ordered Continue daily weights Follow low-salt diet Keep all physician appointments YELLOW ZONE MEANS: Your symptoms may indicate that you need an adjustment of your medications Call Home Health VNA at Your Nurse s Name: Instructions: RED ZONE MEANS: You need to be evaluated by a physician right away Call your physician right away! Physician: Number: all your physician immediately if you are going into the RED one. Adapted from Christus Schumpert Health System, Shreveport, LA Overview Studies show that 40 80% of the medical information patients receive is forgotten immediately 1 and that nearly half of the information retained is incorrect 2. Teach back is a way to confirm that what you have explained to the patient what they need to know in a manner that the patient understands. It involves asking the patients to explain or demonstrate what they have been told. Teach Back Method: Start slowly: Only give the patient 2 3 new education items at a time Keep it simple: Avoid medical terms. Use simple words that anyone will understand. Plan your approach: Think about how you will ask the patient for teachback information based on your topic. Use handouts: Verbally review/read all handouts to the patient and stress the important information. Clarify: Clarify your information until the patient can correctly describe in their own words what they are going to do. 10

11 Things to keep in mind: This is not a test of the patient s knowledge: This is a test of how well you explained the concept. Use with everyone: Use teach back when you think the person understands and when you think someone is struggling with your directions. Do not ask a patient, Do you understand? The clinician takes responsibility for adequate teaching: If the patient cannot explain correctly, assume that you have not provided adequate teaching. Reteach using an alternate approach. Examples of Teach Back education: I want to be sure that I explained your medication correctly. Can you tell me how you are going to take this medicine? We covered a lot today about your diabetes; I want to make sure I explained things clearly. So let s review what we discuss. What are 3 strategies that will help you control you diabetes? What are you going to do tomorrow morning before taking you meds? When your friends/family asks you about this medication, what are you going to tell them? References: Kessels RP. Patients memory for medical information. J R Soc Med. May 2003; 96(5): Anderson JL, Dodman S, Kopelman M, Fleming A. Patient information recall in a rheumatology clinic. Rheumatology. 1979;18(1): Removing barriers to better, safer care, Health literacy and patient safety: Help patients understand, Manual for clinicians, 2 nd ed., Barry D. Weiss, MD 2007 American Medical Association Foundation and American Medical Association. HHVNA BEST PRACTICES TO REDUCE RE-HOSPITALIZATIONS Identify Primary Caregiver/Learner Teach Back/ Zone Tool PATIENT MD Appt. Front Load Visits Medication Reconciliation Revise record audit tool to include assessment of medication reconciliation Review CAHPS patient satisfaction medication questions and scores on a monthly basis Review the quarterly Q and A s sent out by CMS related to medication oasis questions 11

12 Initiate software update request to vendor for detailed medication drop downs Monitor ACH results monthly-comparing OCS to Home Health Compare and Casper Present CQI projects for Medication Management and Reducing ACH to Clinical Management Team and Performance Improvement Committee 12

13 Home Health Compare

14 Home Health Compare 2012 Identify all STAAR patients on admission Participate on STAAR committees in our local area hospitals Work directly with the Transition Coaches on Medication Reconciliation Develop effective hand-off communication to and from all referring agencies Utilize the same educational materials sent home with patient from hospital 14