Truth or Consequences, Best Medication List Practices to Deliver Best Care Leaning & Action Network Session
Introduction David Cook (5 minutes) Housekeeping: - In event of a fire? - Restrooms? David R. Cook 801-892-6623 (direct) dcook@healthinsight.org
Introduction David Cook (5 minutes) Agenda: Introduction 5 minutes (Dave Cook) Frame the Problem 20 minutes (Karen Gunning, PharmD, BCPS, FCCP and Emily Hays, PharmD) Workflow Analysis 15 minutes (Dave Cook) World Café 45 minutes (Everyone) Action Plan 20 minutes (Dave Cook) Upcoming Events & Follow-up 15 minutes (Dave Cook)
Objectives Objective of Session: Learn and showcase effective patient engagement techniques and barriers to med reconciliation (electronic and paper) Identify areas to find data (chie, patient, family, pharmacy, hospital) Identify communications and workflow best practices
TRUTH OR CONSEQUENCES: BEST MEDICATION LIST PRACTICES TO DELIVER BEST CARE IMPORTANCE OF MEDICATION RECONCILIATION
Medication reconciliation What is it: Identifying the patient s complete medication regimen - Prescription, OTC, herbals, vitamins, supplements - Dose, frequency, route Documenting medications and doses the patient is actually taking Documenting new medications, discontinued medications, and dose adjustments Verification, Clarification and Reconciliation When is it performed: Upon admission, transfer to a different unit, and at discharge At every outpatient clinic visit
Medication reconciliation Why bother? Avoid medication errors Reduce readmissions Reduce costs Provide patient education Assess barriers to medication adherence Facilitate communication between providers Improve quality of care
Specific Goals for Decreasing Adverse Events & Errors Avoiding Potential Drug-Drug Interactions Potentially Inappropriate Dosing Potential Drug-Disease Interactions Potentially Inappropriate Therapy and Duplications Monitoring and Preventing Potential Adverse Drug Events
Medication reconciliation The statistics Half of hospital medication errors occur when ordering medications upon hospital admission Medication discrepancy is the most common drug-related problem at the time of discharge Causes 50% of all preventable ADEs 30 days after discharge 1.5 million preventable adverse drug events occur annually $3 billion per year
Reconciliation Pitfalls in the Medical Office Missing information 72% in one study Dose Dosage form Route Frequency Erroneous information can have serious consequences Owen MC et al. Evaluation of Medication List Safety, Completeness and Annotation.
Process Change for Office Medication Reconciliation: Medical Office Staff Assure the accuracy of each patient s medication list What is accurate? Can patient medication list review improve accuracy? Ask about nonprescription therapy, herbal and supplements What other things are you doing to improve (maintain) your health? Poly-provider medications from outside providers CALL THE PHARMACY Distribute printed medication list at the end of each visit this should be THE LIST
Process Change for Office Medication Reconciliation: Clinical Staff Review alerts and adjust prescribing as necessary Critical assessment for drug related problems Drug-Drug Interactions Dosing Drug-Disease Interactions***** Duplications Monitoring for Potential Adverse Drug Events Implement a practice refill protocol Helps to improve reconciliation for patients who don t come in! EHR system helps.
Transitions of care A case for medication reconciliation
Med rec during transitions of care RH is a 79 year old Russian-speaking male PMH Anxiety Atrial fibrillation CAD Depression HTN Insomnia HLD Recently admitted for AAA rupture and repair
Med rec during transitions of care Medications per PCP record at time of admit Escitalopram 10mg daily Zolpidem 5mg daily Flovent HFA inhaler twice daily Albuterol inhaler as needed Atorvastatin 40mg daily Nitroglycerin sublingual tablet as needed Rivaroxaban 20mg daily Atenolol 12.5mg daily Per the last 2 clinic notes patient taking medications as directed
Med rec during transitions of care Inpatient pharmacist admit med rec Escitalopram 10mg daily Zolpidem 5mg daily Flovent HFA inhaler twice daily Albuterol inhaler as needed Atorvastatin 40mg daily Nitroglycerin sublingual tablet as needed Rivaroxaban 20mg daily Atenolol 12.5mg daily Metoprolol 25mg daily
Med rec during transitions of care Discharge medication list Escitalopram 10mg daily; mirtazapine 15mg started Zolpidem 5mg daily Flovent HFA inhaler twice daily Albuterol inhaler as needed Atorvastatin 40mg daily; simvastatin 80mg started Nitroglycerin sublingual tablet as needed Rivaroxaban 20mg daily; aspirin 81mg started Atenolol 12.5mg daily Metoprolol 25mg daily
Med rec during transitions of care Follow-up in clinic after hospitalization Not taking mirtazapine or escitalopram Not taking aspirin or rivaroxaban Not taking metoprolol or atenolol Not taking simvastatin Taking zolpidem as needed Taking albuterol as needed Taking fluticasone as needed Taking nitrogycerin as needed Patient followed by a cardiologist, urologist, geriatrician, and family medicine physician
A comparison of the medication lists PCP List Escitalopram 10mg daily Zolpidem 5mg daily Flovent HFA inhaler twice daily Albuterol inhaler PRN Atorvastatin 40mg daily Nitroglycerin PRN Rivaroxaban 20mg daily Atenolol 12.5mg daily DC List Mirtazapine 15mg Zolpidem 5mg daily Flovent HFA inhaler twice daily Albuterol inhaler PRN Simvastatin 80mg daily Nitroglycerin PRN Aspirin 81mg Metoprolol 25mg daily Patient List Zolpidem 5mg PRN Albuterol inhaler PRN Flovent HFA PRN Nitrogycerin PRN
Med rec during transitions of care Med rec helped to identify barriers to patient care Poor compliance Language barrier Lack of understanding of medication therapy Multiple providers Med rec helped to overcome barriers to patient care Simplify medication regimen Communicate with patient via interpreter Patient and family education on medications and disease states Facilitate communication between providers
Workflow Analysis 20 minutes Dave Cook Work and process flow charts (or maps) are essentially the same in that they are a graphical view of a process. They can be used to map work or process flow to identify opportunities for improvement.
Workflow Analysis 20 minutes A flowchart outlines current workflow and helps identify: Successful medication reconciliation practices. Current roles and responsibilities. Potential failures. Unnecessary redundancies and gaps in the process. Focus on the Who, What, Where, When, and How? If EHR based what prompts, reminders, task lists are involved. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation AHRQ Aug 2012
Workflow Analysis 20 minutes 1. Who obtains a medication list? 2. What is captured during a medication history interview? 3. When is a medication history obtained? 4. Where is the medication history documented within the patient s medical record? 5. How is a medication history documented (i.e., structured paper form; electronic entry; etc.)? 6. How do you monitor and measure that medication histories are obtained and documented appropriately?
Workflow Analysis Example Take 10 minutes and map out the workflow in your care setting
Workflow Analysis Example Obtain patient medication list Obtain medical record medication list Additional Data Gathering? Gather additional data (call family, pharmacy, data repository) Reconcile lists to get Current Med List Optimize the List Update/Document the List for current visit Take 10 minutes and map out the workflow in your care setting Give Lists of Meds to Patient Include list of medications in communication to next care provider
World Café Intro World Café 5 questions - Barriers, Best Practices, Tools, Communication Techniques, and Find the Data Able to participate at 3 tables. We will rotate every 15 minutes facilitated discussion Paper on the tables and markers. If you have an idea that comes to mind while you re talking write it down
World Café - Discussion at each table Table 1: Barriers to effective med reconciliation? Table 2: Best practices for effective med reconciliation? Table 3: Tools to engage patients in the process? Table 4: Communication techniques that can be used with patients to improve accuracy? Table 5: Where can you find the data?
What is Your Plan of Action? What is your Plan of Action? Step One: Based on what you heard today, pick an action that you can implement to improve patient-centered care. Patient Centered Ideas for Action: Assess current patient engagement practices for gaps Improve cultural competency Assess health literacy barriers Provide care plans/visit summaries in non-medical language Implement Personal Health records Implement an electronic patient portal Train patients to plan their visits Use teach back or AskMe3 Train staff in motivational interviewing Train staff in coaching Develop a panel of patient experts to advise you Ideas I heard today that I like: Here are some ideas to get you started: Measurement Ideas: Patient satisfaction scores # of times a tool is used each day # of staff trained in # of meetings with a patient story shared # of meetings with a patient participant # of new templates with selfmanagement assessment developed and used People I met today I want to contact: Consider the ideas on page 13. Fill out your plan for action on page 14. Share with your table what your plan is. Go to action!
Tell us about your experience today There are two evaluations: 1. White Evaluation confidential This page is completed without listing your name. Please rate the morning plenary presentations and the afternoon presentation you attended. 2. Blue evaluation Please fill in your name and contact information To request CME credit and follow up technical assistance as needed. When you have completed both pages of the evaluation, please turn them in separately as you leave. Thank you for your participation and feedback!