Medication Reconciliation for the Elderly Population

H. Edward Davidson, PharmD, MPHAsst. Professor, Clinical Internal MedicineEastern Virginia Medical SchoolPartner, Insight Therapeutics, LLC

Learning Objectives

To define medication reconciliation and its role in patient-centered care

To illustrate the types of medication related problems associated with transitions of care

To describe a method for health care providers and institutions to evaluate their transition of care processes

“Medications are probably the single most important health care technology in preventing illness, disability, and death in the geriatric population.”

Avorn J. Medication use and the elderly: current status and opportunities. Health Affairs 1995.

Clinical Practice Guidelines, the Elderly, and Multiple Comorbid Conditions

Hypothetical 79-yr-old woman with COPD, Type 2 DM, osteoarthritis, hypertension, and osteoporosis

If followed published CPGs wouldBe prescribed 12 routine medicationsCost of $406/month

Implications in pay-for-performance initiativesIncrease risk of medication related problemsDifferent settings, different goalsPotential for diminished quality of care

Boyd CM et al. JAMA 2005;295:716-24.

Adverse Drug Events and the Elderly

Individuals > 65 yrs more likely than younger to suffer an ADE; RR 2.4 (95% CI 1.8-3.0)

Budnitz DS et al. JAMA 2006:296:1858-66

Budnitz et al. New Engl J Med 2011;365:2002-12.

Independent Risk Factors for Having a Preventable ADE in NFs

Risk Factor Odds Ratio 95% CI

Male 0.55 0.30 - 0.99

No. regularly scheduled meds

0-45-67-8>=9

1.01.73.22.9

Referent0.83 - 3.51.4 - 6.91.3 - 6.8

New resident+ 2.9 1.5 -5.7

+within 60 days of admission

Field TS, Gurwitz JH et al. Arch Intern Med 2001;161:1629-34.

What is Medication Reconciliation?Joint Commission:

The process of comparing a patient's medication orders to all of the medications that the patient has been taking

Reconciliation is done to avoid medication errors such as omissions, duplications, interactions, and the need to continue medications

Provides the patient/resident (or family) with written information on the medications they should take

Explains the importance of managing medication information when he/she leaves the organization’s care

Evolution of Medication Reconciliation

NPSG.03.06.01: Maintain and communicate accurate patient medication information

Implemented 7/2011

NPSG.08.01.01: Accurately and completely reconcile medications across continuum of

care

Implemented 1/2006

Care Transitions After Acute Care

Hospital

Home64%

77%

13%

11%

Nursing

Facility

Hospital or TCU

16% 10%

74%

TCU = Transitional Care Unit

Coleman EA et al. Health Svcs Research 2004;37:1423-40.

Hospital Admission

On hospital admission, more than 50% of patients have at least one medication discrepancy*

Approximately 40% of those have potential to cause harm

Cornish PL et al. Arch Intern Med 2005;165:424-9.

* Discrepancy defined as error between admission medication orders and patient interview of medication history.

Hospital Discharge

On discharge from the hospital, 30% of patients have at least one medication discrepancy* with the potential to cause possible or probable harm

Kwan Y et al. Arch Intern Med 2007;167:1034-40.

*Most common discrepancy is omission of pre-admit medication.

Adverse Events in Nursing Home Residents Transferred to the Hospital

122 nursing home to hospital transfers98% returned to the nursing homeIn 86% of transfers, at least one medication

order was altered (mean 1.4)65% - discontinued19% - dose changes10% - substitutions

20% of changes resulted in an adverse event

Boockvar KS, Fishman E, Kyriacou CK et al. Arch Intern Med 2004;164:545-50.

Patient-Level Contributing Factors

Non-intentional non-adherence 34%

Money/financial barriers 6%

Intentional non-adherence 5%

Didn’t fill prescription 5%

Other 1%

Subtotal 51%

Coleman EA, Smith JD, Raha D, Min SJ. Arch Intern Med. 2005;165:1842-7.

System-Level Contributing FactorsD/C instructions incomplete/illegible 16%

Conflicting info from different sources

15%

Duplicative prescribing 8%

Incorrect label 4%

Other 7%

Subtotal 49%

Coleman EA, Smith JD, Raha D, Min SJ. Arch Intern Med. 2005;165:1842-7.

Best Practices: Medication ReconciliationPharmacist involvement

Inpatient setting on intake and dischargePost-discharge assessment/follow-upIn-home review

Prioritize effortsHigh-risk patients (number of medications,

disease conditions (e.g., COPD, MI, heart failure)

High-risk medications; opioids, insulin, anticoagulants/antiplatelets, digoxin, oral hypoglycemic agents

Medication List Toolkit

www.patientsafety.org/page/109587/

Why Evaluation?

Evaluation

Improvement

Opportunities

Did process improve

the outcome

?

Performance as

expected over time

Evaluation is the conscious reflection on what we do

Evaluation ResearchMore rigorous than basic QI methods

Involves developing an evaluable model A collective effort of all stakeholders

Use of a measurement chart to identify variables

Usually involves assessing baseline performance and comparing to a post-intervention period (quasi-experimental research designs)

Evaluation Scenario

Rationale: Vulnerable elders OIG scrutiny (Medicare costs) Significant problems documented

Nursing Home

Hospital/ED

Environmental Scan For MeasuresJoint Commission

National Quality Forum

Institute for Healthcare Information

ACOVE

CMS

AHRQ

Identify Process Nodes

Case study: In a nursing home to hospital bi-directional transfer, you may consider that there are six exchanges

Exchange 1: Preparation in nursing home to transfer patient to hospital (nursing home handover)

Exchange 2: EMS/Ambulance transport

Exchange 3: Hospital receipt of patient

Exchange 4: Preparation in hospital to transfer patient back to nursing home (hospital handover)

Exchange 5: EMS/Ambulance transport

Exchange 6: Nursing home receipt of patient

Determine Evaluation Questions

Q 1

• Is the appropriate information being communicated to the ED/hospital by nursing home staff?

Q 2

• Is there documentation in the nursing home medical record of communication with the primary care physician about the ED/hospital transfer?

• Is there documentation in the nursing home medical record of communication with family/caregiver about transfer of the resident?

Develop Evaluation Matrix

Collect Data

Assess Current Performance

Baseline Evaluation

0%

20%

40%

60%

80%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Question #

% o

f ch

arts

wit

h Y

es r

esp

on

se

Trend Results Over Time

0%

20%

40%

60%

80%

100%

baseline Jul-08 Aug-08 Sep-08 Oct-08 Nov-08

Time Point

% o

f Cha

rts

with

Yes

Res

pons

e

Question 6

Question 8

Question 9

Question 15

minimum allowed

original intervention modified interventionOriginal intervention Modified intervention

Web-based Evaluation Tool

What Can We Do?Evaluate our own practice settingsSeek guidance of others:

Example - www.ntocc.org, www.cfmc.org/integratingcare/toolkit.htm

Assure patient has: An updated medication list at each encounter An understanding of treatment plan An understanding of their role in care

Assure providers have: An understanding of patient and caregiver preferences Knowledge of practice environment – policies, IT, etc. Access to tools to assist in improving care transitions, and hence,

communication of an accurate medication list