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Section2.0:MedicationSafetyduringTransitionsofCare:ClinicalImplications–IntroductionPharmacistsareavaluableresourceforpatientsandhealthcareprofessionalstooptimizemedicationefficacyandsafety.Seniorcarepharmacistsarespeciallytrainedinelderco-morbiditiesandcomplexmedicationmanagement.Duringtransitionsofcare,pharmacistsareinauniquepositionofinterfacingwithpatientsinallcaresettings.Caretransitionsthuspresenttheopportunityforpharmaciststodemonstratetheirclinicalexpertisetoyieldpositiveclinicaloutcomesandimprovequalitycare.TheMedicationSafetyduringTransitionsofCare(MSTOC)Toolkitincludesamultitudeofpracticalclinicalresourcesforpharmacistsinanycaresetting.The“ClinicalImplications”portionofthetoolkitisacollectionofresources,guidanceandlinkstomaterialsintendedtoassistinidentifyingandfocusingonkeymedicationclassesanddiseasestatestooptimizemedicationsafetyduringtransitionsofcare.Theclinicalimplicationsportionofthetoolkitisdividedintothefollowingsixsections:

• Section2.1ToolstoIdentifyKeyDiseaseStates• Section2.2ToolstoIdentifyHighRiskMedications• Section2.3ToolstoIdentifyPotentiallyInappropriateMedications• Section2.4ToolstoClassifyMedication-RelatedProblems&

MedicationErrors• Section2.5ToolstoManageMedicationsSafely• Section2.6ToolstoImproveTransitionsofCareProcesses

Eachsectionincludesbackgroundinformationandanintroductoryoverviewofincludedresourcematerials.SectionsarealsoaccompaniedbysummaryPowerPoint©slidesthatmaystandaloneasteachingmodulestoprovideeducationtopharmacistcolleaguesorotherhealthcareprofessionals.MedicationSafetyduringTransitionsofCare:ClinicalImplicationsSection2.1:ToolstoIdentifyKeyDiseaseStatesTheCentersforMedicare&MedicaidServices(CMS)HospitalReadmissionsReductionProgram(HRRP)isdesignedtoimprovehealthcareforpeoplewithMedicarebylinkinghospitalpaymentstoqualityofcareratherthanquantityofservicesprovided.

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TheHRRPprovidesfinancialincentivestohospitalstoreducecostlyandunnecessaryhospitalreadmissionsthroughbettercoordinationofcaretransitionsandimprovedqualityofcaregiventopatientswithMedicare.InOctober2012,CMSbeganreducingMedicarepaymentsforInpatientProspectivePaymentSystem(IPPS)hospitalswithexcessreadmissions.Whentheprogramstarted,hospitalsweremeasuredforthereadmissionratesofpatientswiththefollowingkeydiseasestates:acutemyocardialinfarction(AMI),heartfailure,andpneumonia.In2012,COPD,electivehip/kneereplacementandcoronaryarterybypassgraftsurgerywereaddedtothislist.Excessreadmissionsaremeasuredbyaratiodividingahospital’snumberof“predicted”30-dayreadmissionsforthesekeydiseasestatesbythenumberthatwouldbe“expected”inanaveragehospitalwithsimilarpatients.Aratiogreaterthan1.0000indicatesexcessreadmissions.Hospitalsattemptingtolowertherateofreadmissionsare:

• Focusingonbettercoordinationofcareandcommunicationbetweenproviders,patientsandtheircaregivers.

• Improvingdischargeplanning,educationandfollow-upfordischargedpatients.• Usingelectronicmedicalrecordstoshareinformationandprovidecontinuityofcare.

Whilepharmacistinvolvementinallcaretransitionsisbeneficial,focusingonthekeydiseasestatesmeasuredintheHRRPwillenhancethevalueofpartnershipsbetweenhospitalsanddownstreamcaresites(e.g.long-termcare,post-acutecarerehabilitation,community).

• Resource:ThislinksdirectsyoutoCMS’scomprehensiveinformationontheHRRPProgram:https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html

MedicationSafetyduringTransitionsofCare:ClinicalImplicationsSection2.2:ToolstoIdentifyHighRiskMedicationsThereismuchliteratureontheidentificationofhighriskmedications.A2014reportbytheUSDepartmentofHealthandHumanServices’OfficeofInspectorGeneral(OIG)foundthat22%ofMedicarebeneficiariesinskillednursingfacilitiesexperienceadverseeventswithinthefirst35daysoftheirstay.Oftheseidentifiedadverseevents,37%wererelatedtomedicationsandprimarilyassociatedwithconditionstreatedwithhypoglycemics,anticoagulantsandopiates.Attheconclusionofthereport,theOIGrecommendedthatCMScollaboratewiththeAgencyforHealthcareResearchandQuality(AHRQ)toincreaseawarenessofadverseeventsinnursing

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homesandtodevelopsafetymethodologiestoreducetheseevents(i.e.creatingofalistofpotentialnursinghomeadverseevents).

• Resource:Thislinkdirectyouto2014OIGreport:http://oig.hhs.gov/oei/reports/oei-06-11-00370.pdf

AdverseEventsinNursingHomesInresponsetorecommendationsfromthe2014OIGreportabove,CMSincorporatedresourcesinitsQualityAssurance&PerformanceImprovement(QAPI)websitetohelphealthcareprovidersidentifyandinvestigateadverseevents(AEs)innursinghomes.CMSalsoencouragesthedevelopmentofsystem-wideprocessesdesignedtomitigateAErisk.

• Resource:ThislinkdirectsyoutoCMS’sQAPIsiteonAEsinnursinghomes:https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Adverse-Events-NHs.html

OnetoolontheCMSQAPIsitelistspotentialAEsinnursinghomes.UsingtheOIGreport,CMSandAHRQcollaboratedtocreatealistofthemostcommonpotentiallypreventableAEsrelatedtomedications,residentcareandinfections.

• Resource:ThislinkdirectsyoutoalistofpotentiallypreventableAEswithintheCMSQAPIsite:https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/Potentially-Preventable-Adverse-Events.pdf

CMSAdverseDrugEventTriggerToolThirtysevenpercentofAEsidentifiedinthe2014OIGreportwereadversedrugevents(ADEs)involvingmedications.ThesecondmostfrequentADEwasexcessivebleedingrelatedtoanticoagulantuse.Thesefindingscontinuetobesupportedintheliterature.CMSdevelopedaresourcedocumentthatlistscommonpotentiallypreventableADEs,riskfactorsrelatedtothoseevents,triggers(i.e.signs,symptoms,interventions)whichcouldindicatethatanADEoccurred;andsurveyorprobestoassistintheevaluationofhighriskmedicationsafetysystems.

• Resource:ThislinkdirectsyoutotheADEtriggertoolwithintheCMSQAPIsite:https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/Adverse-Drug-Event-Trigger-Tool.pdf

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CMSFocusedSurveyonMedicationSafetySystemsDuringitscollaborationwithAHRQ,CMSbegindevelopingandtestingaFocusedSurveyonMedicationSafetySystemstolookatnursinghomepracticearoundhigh-riskandproblempronemedications.Theabove-mentionedCMSAdverseDrugEventTriggerToolandlistsofpotentiallypreventableAEsareessentialcomponentsofthissurveyprocess.AsofAugust2017,thisfocusedsurveyremainsinpilotphase.Itwilllikelybecomepartoftheannualstatesurveyprocessinthefuture.ThesurveyessentialsincludeareviewofmedicationsafetysystemsthatidentifypreventableADEsandtheriskfactorsrelatedtothoseevents.

• ReviewmedicationsafetysystemsusingADEtriggertool• IdentifypreventableADEsthathaveoccurredorwilloccur• MitigateriskfactorsrelatedtoADEs

• Resource:ThislinkdirectsyoutotheCMSMemoannouncingtheMedicationSafety

SystemsFocusedSurvey:https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-15-47.html

InstituteforHealthcareImprovement(IHI)High-AlertMedicationSafetyResourcesInefforttoimprovehealthandhealthcareworldwide,theInstituteforHealthcareImprovement(IHI)websiteincludesnumerousresourcesandtoolsrelatedtomedicationsafety.Thehigh-alertmedicationsafetypagedefineshigh-alertorhigh-hazardmedicationsasdrugsmostlikelytocausesignificantharm,especiallywhenusedinerrorbutevenwhenusedasintended.TheIHItoolsfocusonmedicationclassesthatmorefrequentlycauseharm(i.e.anticoagulants,narcotics,opiates,sedativesandinsulinwhichcancauseAEssuchasbleeding,somnolence,hypotensionandhypoglycemia).Recognizingthatsafemedicationpracticescanreducethepotentialforharm,IHIalsodevelopedahow-toguidetopreventharmfromhigh-alertmedications.

• Resource:AccessingtheIHItoolsrequiresfreeregistration.Thislinkdirectsyoutothehigh-alertmedicationsafetysectionofIHIsite:http://www.ihi.org/topics/highalertmedicationsafety/pages/default.aspx

InstituteforSafeMedicationPractices(ISMP)ListsofHigh-AlertMedicationsOnerecommendedresourceontheIHIpageisTheInstituteforSafeMedicationPractices(ISMP)listsofhigh-alertmedicationsincommunity/ambulatoryandacutecaresettings.The

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community/ambulatorylistincludes8categoriesand8specificmedications.Theacutecaresettinglistincludes22categoriesand12specificmedications.TheselistsareperiodicallyupdatedbasedonerrorreportssubmittedtotheMedicationErrorsReportingProgram(MERP),reportsofharmfulerrorsintheliterature,andinputfrompractitionersandsafetyexperts.

• Resource:ThislinkdirectsyoutoISMP’sprintablepdflistofhigh-alertmedicationsincommunity/ambulatoryhealthcare:http://ismp.org/communityRx/tools/highAlert-community.pdf

• Resource:ThislinkdirectsyoutoISMP’sprintablepdflistofhigh-alertmedicationsin

acutecaresettings:http://www.ismp.org/Tools/highalertmedications.pdf

HEDIS®MeasuresTheHealthcareEffectivenessDataandInformationSet(HEDIS®)isasetofhealthcareperformancemeasuresthatdatebacktothe1980s.HEDIS®isnowaregisteredtrademarkoftheNationalCommitteeforQualityAssurance(NCQA)thatcollectsqualitymeasuresforphysicians,PPOsandotherorganizationsonbehalfofCMSandstateagencies.HEDIS®consistsof81specificmeasuresover5domainsofcare.SurveydataiscollecteddirectlyfromhealthplansandPPOsthroughtheHealthcareOrganizationQuestionnaire(HOQ).NonsurveydataiscollectedthroughtheInteractiveDataSubmissionSystem(IDSS).HEDISisdesignedtoprovidepurchasersandconsumerswiththeinformationtheyneedtoreliablycomparetheperformanceofhealthcareplans.NCQA’smeasuresaddressstandardizedperformancemeasuresforcareofchronicconditionssuchasasthma,diabetes,chronicobstructivepulmonarydisease(COPD),heartfailure(HF)andischemicvasculardisease(IVD),aswellaspreventativemeasuresfortobaccouse,influenzavaccinationandpneumococcalvaccination.“UseofHRMsintheElderly”isonemetricincludedinHEDIS2017thatcalculates:

• %ofmembers66yearsandolderwhoreceivedatleastoneHRM• %ofmembers66yearsandolderwhoreceivedatleasttwoHRMs

TheNationalDrugCode(NDC)ListsincludeHRMsthatalignwiththe2015AmericanGeriatricsSocietyBeersCriteria.

• Resource:ThislinkdirectsyoutotheNDCListprovidedontheNCQAsite:http://www.ncqa.org/hedis-quality-measurement/hedis-measures/hedis-2017/hedis-2017-ndc-license/hedis-2017-final-ndc-lists

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Section2.3:ToolstoIdentifyPotentiallyInappropriateMedicationsPotentiallyinappropriatemedications(PIMs)arethosewhoseuseinolderadultshasproducedevidenceofpooroutcomes.PIMsuseinvulnerableolderadultsisincorporatedintomanyqualityandsafetymeasures.AmericanGeriatricsSociety(AGS)BeersCriteria2015TheAGSBeerscriteriaisonesourceofidentifyingPIMsbestavoidedinolderadults.The2012AGSBeersCriteriawereupdatedin2015toincorporatenewevidenceoncurrentlylistedPIMsandnewmedicationsandconditionsnotpreviouslyaddressedinthecriteria.Neededexceptionswerealsoaddedtothecriteriatomakethemmoreindividualizedandrelevant.EachPIMrecommendationisnowgradedbasedonstrengthandlevelofevidenceonmedication-relatedproblems(MRPs)andadversedrugevents(ADEs).ThefinalupdatedCriteriaaredividedintothreecategories:

• Table2:PIMUseinOlderAdults• Table3:PIMUseinOlderAdultsDuetoDrug-DiseaseorDrug-SyndromeInteractions

thatMayExacerbatetheDiseaseorSyndrome• Table4:PIMstobeUsedwithCautioninOlderAdults

Newcompanionresourcesinthe2015editioninclude:how-to-useguide,alternativetherapiesforPIMs,moredetailedguidancefordrug-druginteractionsandrenaldoseadjustments,pocketcards,andpatienteducationmaterials.ItisimportanttonotethattheBeerscriteriaarenotapplicabletoseniorsrequiringpalliativeorhospicecare.

• Resource:Thislinkdirectsyoutothe2015Beerscriteriaandassociatedresources:http://geriatricscareonline.org/toc/american-geriatrics-society-updated-beers-criteria-for-potentially-inappropriate-medication-use-in-older-adults/CL001

ZhanCriteriaforPIMUseintheElderlyZhanmodifiedthe1997BeersCriteriatofocusonidentifyingPIMuseinthecommunity-dwellingelderly.Apanelofexpertsclassified33medicationsfromtheBeersCriteriaintothreecategories:drugsthatshouldalwaysbeavoided,arerarelyappropriate,orhavesomeindicationsbutareoftenmisused.PrevalenceofuseofthesePIMswasmeasuredusingthe1996MedicalExpenditurePanelSurvey,anationallyrepresentativesurveyoftheU.S.non-institutionalizedpopulation.RiskfactorsforPIMuseidentifiedinthisstudyincludepoorhealthandpolypharmacy.

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ZhanCriteriaContinued

• Resource:ThisisthecitationfortheZahncriteria:ZhanC,SanglJ,BiermanAS;etal.Potentiallyinappropriatemedicationuseinthecommunity-dwellingelderly:findingsfromthe1996MedicalExpenditurePanelSurvey.JAMA.2001;286(22):2823-9.

ScreeningToolofOlderPeople'sPrescriptions(STOPP)andScreeningTooltoAlerttoRightTreatment(START)CriteriaforPotentiallyInappropriatePrescribinginOlderPeople:Ver2TheScreeningToolofOlderPeople'sPrescriptions(STOPP)andScreeningTooltoAlerttoRightTreatment(START)CriteriaforPotentiallyInappropriatePrescribinginOlderPeoplewerefirstpublishedin2008.In2015,theseoriginalcriteriawerereviewedtoaddnewevidence-basedcriteriaandremoveanyobsoletecriteria.ThepurposeoftheSTOPPcriteriaistominimizeinappropriateprescribingtodecreaseadverseclinicaloutcomesinolderadultswhilethepurposeoftheSTARTcriteriaistoidentifypotentialprescribingomissionsinolderadults.UnlikeBeersCriteriamedications,STOPPcriteriamedicationsaresignificantlyassociatedwithadversedrugevents(ADEs).STOPP/STARTcriteriahavepracticalclinicalvalueinthattheycanbeappliedasasingleinterventiontoimprovemedicationappropriatenessandreducetheincidenceofADEs.

• Resource:Thisisthecitationforthe2015STOPP/STARTcriteria:DenisO'Mahony,DavidO'Sullivan,StephenByrne,etal.STOPP/STARTcriteriaforpotentiallyinappropriateprescribinginolderpeople:version2,AgeandAgeing.2015;44(2):213-8https://doi.org/10.1093/ageing/afu145

AmericanGeriatricsSociety(AGS)WorkwiththeAmericanBoardofInternalMedicine(ABIM)Foundation's“ChoosingWisely®”CampaignAGSpartneredwiththeABIMFoundation’s“ChoosingWisely®”Campaigntoimprovequalityofcareanddecreaseunnecessaryhealthcarespending.Thiscampaignisdesignedtoeducatepatients,healthcareprofessionals,andfamilycaregiversaboutsafetyandefficacyofvarioushealthcarechoices.AGS’slistof“TenThingsCliniciansandPatientsShouldQuestion”includespotentiallyinappropriateprescribingforthefollowingmedicationclasses:antipsychoticsforbehavioralandpsychologicalsymptomsofdementia;hypoglycemictoachieveanHbA1clessthan7.5%;sedative/hypnoticsforinsomnia,agitationordelirium;antimicrobialsforasymptomaticbacteriuria;cholinesteraseinhibitorsfordementia;andappetitestimulantsforanorexiaorcachexia.

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OneAGSrecommendationis:“Don’tprescribeamedicationwithoutconductingadrugregimenreview”becausepolypharmacyincreasesriskforsideeffects,inappropriateprescribing,diminishedadherence,adversedrugreactions,cognitiveimpairment,fallsandfunctionaldecline.Medicationreviewmayidentifyhigh-riskmedications,drug-druginteractions,medicationscontinuedbeyondtheirindication,unnecessarymedicationsandunderuseofmedications,andmayreducemedicationburden.

• Resource:ThislinkdirectsyoutoalltheAGSrecommendationsontheChoosingWisely®

site:http://www.choosingwisely.org/societies/american-geriatrics-society/MedicationAppropriatenessIndex(MAI)Hanlon’sMedicationAppropriatenessIndex(MAI)wasdevelopedtodetectpotentiallyinappropriateprescribingwithasetof10explicitquestionsthatpredictadversehealthoutcomes.Thequestionnaireasks:

1. Isthereanindicationforthedrug?2. Isthemedicationeffectiveforthecondition?3. Isthedosagecorrect?4. Arethedirectionscorrect?5. Arethedirectionspractical?6. Arethereclinicallysignificantdrug-druginteractions?7. Arethereclinicallysignificantdrug-diseaseinteractions?8. Isthereanyunnecessaryduplicationwithotherdrugs?9. Isthedurationoftherapyacceptable?10. Isthisdrugtheleastexpensivealternativecomparedtoothersofequalutility?

StudiesontheMAIdemonstratethepositiveimpactpharmacistinterventionshaveonimprovingpotentiallyinappropriateprescribinginolderadults.

• Resource:ThisisthecitationfortheMAIquestionnaire:HanlonJT,SchmaderKE,SamsaGP,etal.Amethodforassessingdrugtherapyappropriateness.JClinEpidemiol.1992;45:1045–51.

Assess,Review,Minimize,Optimize,Reassess(ARMOR)ToolTheAssess,Review,Minimize,Optimize,Re-assess(ARMOR)toolisafunctional,interactiveevidence-basedtool.Thetooltakesintoaccountclinicalprofiles,functionalstatus,andphysiologicreservestoimprovefunctionalstatusandmobilityandmakedecisionsaboutchangingordiscontinuingmedications.

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TheARMORtoolisdesignedforuseinSNFresidents:

• Receiving9ormoremedications• Initialassessment• Withfallsorbehavioraldisturbance• Admittedforrehabilitation

Whentestedononenursingfacility,theARMORtoolreducedpolypharmacy,healthcarecosts,andhospitalizations.

• Resource:ThisisthecitationfortheARMORtool:HaqueR.ARMOR:atooltoevaluatepolypharmacyinelderlypersons.AnnalsofLong-TermCare2009;17(6):26–30.

MedicationSafetyduringTransitionsofCare:ClinicalImplicationsSection2.4:ToolstoClassifyMedication-RelatedProblems&MedicationErrorsAnumberoftoolsareavailabletotrackandquantifymedicationerrors,adversedrugevents(ADE)andpotentialadversedrugevents(pADE).Food&DrugAdministration(FDA)MedWatchTheFDA’sMedWatchisaSafetyInformationandAdverseEventReportingProgram.Thisvoluntaryonlinereportingformcanbecompletedbyeitherhealthcareprofessionalsorconsumerstoreportobservedorsuspectedadverseevents(AEs)whichmayinclude:seriousdrugsideeffects,medicationerrors/productuseerrors,productqualityproblems,ortherapeuticfailures.ReportedAEsmayinvolveanyhumanmedicalproduct(i.e.prescriptionorover-the-counterdrugs,biologics,medicaldevices,specialnutritionals,cosmetics,orfoods/beverages).Thereporterispromptedtoenterinformationaboutthepatient,problem,product,device,concomitantproducts,andthemselves.Basedonfiledreports,theFDAreleasestimelysafetyalertsforhumanmedicalproducts(i.e.medications,biologics,medicaldevices,specialnutritionals,andcosmetics).Thesesafetyalertscontainactionableinformationthatmayimpacttreatmentanddiagnosticchoicesforhealthcareprofessionalandconsumers.YoucansignuptoreceiveMedWatchsafetyalertsviae-mail,Twitter©,andRSS.

• Resource:ThislinkdirectsyoutoFDAMedWatch:https://www.fda.gov/safety/medwatch/default.htm

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NationalCoordinatingCouncilforMedicationErrorReportingandPrevention(NCCMERP)IndexTheNationalCoordinatingCouncilforMedicationErrorReportingandPrevention(NCCMERP)definesamedicationerroras“anypreventableeventthatmaycauseorleadtoinappropriatemedicationuseorpatientharmwhilethemedicationisinthecontrolofthehealthcareprofessional,patientorconsumer.Sucheventsmayberelatedtoprofessionalpractice,healthcareproducts,procedures,andsystems,includingprescribing,ordercommunication,productlabeling,packaging,andnomenclature,compounding,dispensing,distribution,administration,education,monitoring,anduse.”NCCMERPcreatedaMedicationErrorIndextostandardizecharacterizationofmedicationerrors.Thisindexconsidersiftheerroractuallyoccurred,iftheerrorreachedthepatient,ifthepatientwasharmedandifso,towhatdegree.Theindexisavailableasbothapiechartandanalgorithmanddefinesthefollowingterms:harm,monitoring,interventionandinterventionnecessarytosustainlife.

• Resource:ThislinkdirectsyoutotheNCCMERPIndex:http://www.nccmerp.org/types-medication-errors

InstituteforSafeMedicationPractices(ISMP)MedicationErrorReportingProgram(MERP)TheNCCMERPindexisusedbytheInstituteforSafeMedicationPractices(ISMP)MedicationErrorReportingProgram(MERP)nationaldatabase.ISMPoperatesthisconfidential,voluntaryreportingprogramtolearnanddisseminateinformationaboutthecausesandfactorsthatcontributetomedicationerrors.ISMPdefinesanADEas“adeviationinthemedicationuseprocessoranundesirableclinicalmanifestationthatisconsequenttoandcausedbytheadministrationoromissionofmedications”andapADEas“ahazardoussituationthatcouldleadtoanerror.”

• Resource:ThislinkdirectsyoutotheISMPsitetoreportamedicationorvaccineerrororhazard:https://www.ismp.org/errorReporting/reportErrortoISMP.aspx

MedicationErrorandAdverseDrugEventReportingSystem(MEADERS)

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TheMedicationErrorandAdverseDrugEventReportingSystem(MEADERS)isusedbytheAgencyforHealthcareResearchandQuality(AHRQ)toreportmedicationerrorsandADEsandpADEs.LikeISMP’sMERPindex,thissystemisalsolinkedtoFDAMedWatch.

• Resource:ThislinkdirectsyoutoAHRQ’sMEADERS:http://www.ahrq.gov/news/events/nac/2012-07-nac/brady/brady0712sl14.html

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VeteransAffairsDrugEventReportingSystem(VADERS)TheVeteranAffairsDrugEventReportingSystem(VADERS)wascreatedtoprovideanelectronicADEreportingtoolfortheVAsystem.UnlikeAHRQ’sMEADERS,pADEsarenotreportedinVADERS.LikeISMP’sMERPandAHRQ’sMEADERS,thissystemisalsolinkedtotheFDAMedWatch.

• Resource:ThislinkdirectsyoutoVADERS:http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3043

UniversityofSouthernCalifornia(USC)MedicationTherapyInterventionandSafetyDocumentationProgramTheUniversityofSouthernCalifornia(USC)MedicationTherapyInterventionandSafetyDocumentationProgrampresentsaprocessforidentifyingandtrackingmedication-relatedproblemsthatrequireinterventionorrecommendationbyapharmacist.ThistoolidentifiesandratesseverityofADEsandpADEswhilequantifyingtheimpactpharmacyserviceshasonqualityandsafetyofmedicationuse.Sincethisprogramispaper-based,itisnotlinkedtotheFDAMedWatch.

• Resource:ThislinkdirectsyoutoUSC’smedicationsafetyprogramdetailedusermanual:http://www.ihconline.org/UserDocs/Pages/USC-Medication-Therapy-Intervention-and-Documentation-Manual--Updated-4-6-2012.pdf

MedicationSafetyduringTransitionsofCare:ClinicalImplicationsSection2.5:ToolstoManageMedicationsSafelyThissectionisdividedinto8Parts:

• Part2.5.1:Anticoagulants• Part2.5.2:Hypoglycemics• Part2.5.3:Opioids• Part2.5.4:Psychotropics• Part2.5.5:Antimicrobials• Part2.5.6:NarrowTherapeuticIndexMedications• Part2.5.7:Anticholinergic/Sedation/FallRiskMedications• Part2.5.8:Pharmacogenomics

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Part2.5.1:AnticoagulantsAnticoagulantsareamongthethreeclassesofmedicationsmostcommonlyassociatedwithadversedrugreactions(ADRs)innursinghomes.StandardizationofpracticescangreatlyreduceADRsfromanticoagulants.TheUniversityofMichiganAnticoagulationToolkitwasproducedbytheMichiganAnticoagulationQualityImprovementInitiative(MAQI2)toprovidehealthcareprofessionalswithup-to-date,reliable,easy-to-useinformationforanticoagulation.Thistoolkitincludes:

• Riskevaluationtoolsforatrialfibrillation,VTE,andbleedingrisk,includingonlinecalculatorsandapps

• Guidanceonanticoagulantselection• Initiationguides,patienteducationmaterials,andlong-termmanagementtoolsfor

warfarinandDOACs

ThistoolkitcanalsobeaccessedthroughaniPhoneapplication.

• Resource:ThislinksdirectsyoutotheMAQI2AnticoagulationToolkit:http://www.anticoagulationtoolkit.org/sites/default/files/toolkit_pdfs/toolkitfull.pdf

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TheInstituteforSafeMedicationPractices(ISMP)providesanumberofservicestoimprovemedicationsafetywithanticoagulationtherapy,including:

• ISMPmedication-safetyself-assessmentforantithrombotictherapy• FailureModeandEffectsAnalysis(FMEA)• Recordedaudioteleconferencesandothereducationalprograms

• Resource:ThislinksdirectsyoutotheISMPImprovingMedicationSafetywith

AnticoagulationTherapypage:http://www.ismp.org/tools/anticoagulantTherapy.asp

TheInstituteforHealthcareImprovement(IHI)proposesmultiplechangesforimprovementtoreduceadverseeventsinvolvinganticoagulants.Suggestedchangesforimprovementinclude:

• Useguidelinesforpre-printedordersforVitaminK• Developawarfarindosingserviceorclinic• Continuetouseanticoagulationflowsheetsafterdischarge• Educatepatientstomanagewarfarintherapyathome

• Resource:ThislinksdirectsyoutotheIHI:ReduceAdverseDrugEventsInvolving

Anticoagulantspage:http://www.ihi.org/resources/Pages/Changes/ReduceAdverseDrugEventsInvolvingAnticoagulants.aspx

Part2.5.2:HypoglycemicsHypoglycemicsareamongthethreeclassesofmedicationsmostcommonlyassociatedwithadversedrugreactionsinnursinghomes.Diabetesismorecommoninolderadultsandisassociatedwithsignificantdiseaseburdenandhighercost.Asthesepatientstransitionfromonesettingtoanother,oneprovidertoanother,theirriskforadverseeventsincreases.ThepositionoftheAmericanDiabetesAssociationisthatdiabeticgoalsandmanagementshouldbetailoredbasedoncomorbiditiesandregimensshouldbesimplifiedtowardshigherclinicaltargets.Furthermore,thesoleuseofslidingscaleinsulin(SSI)shouldbeavoidedinseniors.

• Resource:ThislinksdirectsyoutotheADAStandardofCare:Diabetesmanagementinlong-termcareandskillednursingfacilities:

http://care.diabetesjournals.org/content/39/2/308

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• Resource:ThislinksdirectsyoutotheADAStandardofCare:Glycemiccontrolinolder

adults:http://care.diabetesjournals.org/content/diacare/39/Supplement_1/S81.full.pdf

• Resource:ThislinksdirectsyoutotheSocietyofHospitalMedicine:TheGlycemicControlImplementationGuidehttp://tools.hospitalmedicine.org/resource_rooms/imp_guides/GC/GC_Workbook.pdf

Part2.5.3:OpioidsOpioidsareamongthethreeclassesofmedicationsmostcommonlyassociatedwithadversedrugreactionsinnursinghomes.In2016,theCDCreleasedguidelinesforprescribingopioids.Opioidprescribinghasincreased7.3%from2007to2012with259millionprescriptionswrittenin2012.Therearefewstudiesthathavebeenconductedtoassessthelong-termbenefitsofopioidsforchronicpainvs.long-termeffects,howevertheuseofopioidpainmedicationhasseriousrisks,includingoverdoseandopioidusedisorder.Guidelinesrecommendtreatingchronicnon-cancerpainwithnon-pharmacologicalandnon-opioidmedicationsandtoonlyuseopioidswhenbenefitsoutweighrisks.Theconcurrentuseofopioidsandbenzodiazepinesaretobeavoidedaswell.Thereisconsiderablevariationsinotherfactorsofopioidprescribingincludingdosagethresholdsbasedonmorphinemilligramequivalentsdaily,whoshouldbeprescribing,theuseofevidenceandconflictofinterest.Thereareseveraltoolsintheresourcestohelpwithopioiddosing,conversionandpainassessment:

• Resource:ThislinksdirectsyoutotheInteragencyGuidelineonPrescribingOpioidsforPainbyWashingtonStateMedicalDirectorsGroup2015:http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf

• Resource:ThislinksdirectsyoutoanarticleonManagingPainintheGeriatricPatient:

http://jaoa.org/article.aspx?articleid=2093506

• Resource:ThislinksdirectsyoutotheCDCGuidelinesforPrescribingOpioidsinChronicPain:http://dx.doi.org/10.15585/mmwr.rr6501e1

• Resource:ThislinksdirectsyoutoaCDCdocumentonCommonElementsintheaboveguidelines:

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http://www.cdc.gov/drugoverdose/pdf/common_elements_in_guidelines_for_prescribing_opioids-a.pdf

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• Resource:ThislinksdirectsyoutoAMDAClinicalPracticeGuidelinesforPain:

http://www.paltc.org/topic/pain-management

• Resource:ThislinksdirectsyoutoMedscapeOpioidsEquivalentsandConversionshttp://emedicine.medscape.com/article/2138678-overview

• Resource:Thislinksdirectsyoutoan8stepapproachtoexchangingoneopioidagentor

routofadministrationforanotherhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1069064/

• Resource:ThislinksdirectsyoutoanopioidDosecalculator:

http://opioidcalculator.practicalpainmanagement.com

• Resource:ThislinksdirectsyoutoanOpioidsconverterprogramonGlobalRPh:http://www.globalrph.com/narcoticonv.htm

• Resource:ThislinksdirectsyoutoUniversityofIowaGeriatricPainAssessmenttools:

https://geriatricpain.org/pain-assessment

• Resource:ThislinksdirectsyoutoAMDAguidelinesonPainassessmentinAssistedLivinghttp://www.assistedlivingconsult.com/issues/01-03/ALC1-3_AMDAPain.pdf

Part2.5.4:PsychotropicsIn2012,CMSlaunchedtheNationalPartnershiptoImproveDementiaCareinNursingHomes.Whentheinitialgoalwasmetin2014,CMSalongwiththeAmericanHealthCareAssociation(AHCA)setnewgoalsforfurtherreduction.Theintentistosafelyreducetheofflabeluseofantipsychoticswhichcanproducenegativeoutcomes.Theprogresstowardthisnewgoalispublished.Therearemanytools,programs,andcontinuingeducationontheuseofpsychotropicsaswellascognitiveassessmenttoolsthatcanbeadministeredbysomeoneotherthanthephysician.

• Resource:ThislinksdirectsyoutotheAmericanPsychiatricAssociationPracticeGuidelineontheUseofAntipsychoticstoTreatAgitationorPsychosisinPatientswithDementia:http://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890426807

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• Resource:ThislinksdirectsyoutoIA-ADAPT–ImprovingAntipsychoticAppropriatenessinDementiaPatientstools:https://www.healthcare.uiowa.edu/IGEC/IAAdapt/pharmacist

• Resource:ThislinksdirectsyoutoColoradoHealthCareAssociationandCenterfor

AssistedLiving:Guidelinesforappropriateuseofantipsychotics:http://cmda.us/wp-content/uploads/2015/11/CHCA-Antipsychotic-Guidelines.pdf

• Resource:ThislinksdirectsyoutotheMontrealCognitiveAssessment(MoCA)Test:http://www.mocatest.org/

• Resource:ThislinksdirectsyoutotheAlzheimer’sAssociationCognitiveAssessmentToolkit:http://www.alz.org/documents_custom/141209-CognitiveAssessmentToo-kit-final.pdf

Part2.5.5:AntimicrobialsImprovingtheuseofantibioticsinhealthcaretoprotectpatientsandreducethethreatofantibioticresistanceisanationalpriorityrequiringdiligent“AntibioticStewardship”.AntibioticStewardshipreferstoasetofcommitmentsandactionsdesignedtooptimizeantibiotictherapywhilelimitingtheadverseeffects.Antibioticsareoneofthemostfrequentlyprescribedmedicationisnursinghomeandstudieshaveshownthat40-75%ofthoseareunnecessary.Theseresourceslistedcanhelpinitiateanantibioticstewardshipprogramaswellastoolsforchoosingempirictherapyanddosing.

• Resource:ThislinksdirectsyoutoASCP’sdedicatedwebsiteonantimicrobialstewardship:http://www.ascp.com/amstoolkit

• Resource:ThislinksdirectsyoutoImplementinganAntibioticStewardshipProgram:

GuidelinesbytheInfectiousDiseaseSocietyofAmericaandtheSocietyforHealthcareEpidemiologyofAmerica:http://cid.oxfordjournals.org/content/62/10/1197.long

• Resource:ThislinksdirectsyoutoAlgorithmspromotingAntibioticStewardshipinLong

TermCare:http://www.jamda.com/article/S1525-8610(15)00728-8/abstract

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• Resource:ThislinksdirectsyoutoCDCCoreElementsforAntibioticStewardshipinLongTermCare:http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html

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• Resource:ThislinksdirectsyoutoActionStepsandStrategiestoimplementing

antibioticstewardshipprograminlongtermcare:http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/asp/ltc/apxb.pd

f

• Resource:ThislinksdirectsyoutoGlobalRPhInfectiousDiseaseEmpiricTherapy:http://www.globalrph.com/antibiotic.htm

• Resource:ThislinksdirectsyoutoGlobalRPhPathogenicBacteriaResource:

http://www.globalrph.com/bacterial-strains-anaerobic.htm

• Resource:ThislinksdirectsyoutoGlobalRPhAminoglycoside/VancomycinDosingbylevelscalculator:http://www.globalrph.com/dosebylevels.htm

Part2.5.6:NarrowTherapeuticIndexMedicationsLaboratoryresultscanhelpidentifypatientswhomayneeddrugtherapy,andcanbeusedtoevaluateandmonitorapatient’sresponsetoexistingdata.Itcanalsobeimportantinevaluatingthecourseofadisease.Patientsoftendon’thavethisinformation.Approximatelyhalfofpatient’stakinganarrowtherapeuticindexmedicationdonothaveappropriatemonitoring.

• Resource:Thislinksdirectsyouanarticlewithgeneralinformationabouttherapeuticdrugmonitoring:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2687654/

• Resource:ThisisthecitationforaPharmacistletterlabmonitoringchart:(access

requireslogin) PlDetail-Document,LabMonitoringforCommonMedications.Pharmacist’s

Letter/Prescriber’sLetter.June2014.Part2.5.7:Anticholinergic/Sedation/FallRiskMedicationsAnticholinergicsarecommonlyusedtotreatallergies,colds,bladderproblemsandotherailments.Howeverolderadultsareatgreaterrisktoexperienceadverseclinicaloutcomes.ToolstohelpwiththeassessingtheriskinusingincludeAnticholinergicRiskScalesandDrugBurdenIndex.Alongwithassessingtheuseofanticholinergics,therearealsotoolsforfallriskassessments.

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• Resource:Thislinksdirectsyoutoananticholinergicmedicationlistforpatients:

http://www.public-health.uiowa.edu/cert/education/AnticholinergicBrochure.pdf

• Resource:Thislinksdirectsyoutotheanticholinergiccognitiveburdenscale

http://www.agingbraincare.org/uploads/products/ACB_scale_-_legal_size.pdf

• Resource:ThislinkdirectsyoutotheAnticholinergicRiskScale:

http://www.magellanofaz.com/media/757303/magellan_anticholinergic_risk_scale_2014.pdf

• Resource:ThislinksdirectsyoutoanarticleontheDrugBurdenIndex:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4166346/pdf/cia-9-1503.pdf

• Resource:ThislinksdirectsyoutotheTimedUpandGoTest(TUG)AssessmentTool:

http://www.rehabmeasures.org/PDF%20Library/Timed%20Up%20and%20Go%20Test%20Instructions.pdf

• Resource:ThislinksdirectsyoutoanotherformatoftheTimedUpandGoTest(TUG)

AssessmentTool:http://www.ocagingservicescollaborative.org/wp-content/uploads/2014/07/Timed-Up-and-Go-TUG.pdf

• Resource:ThisisthecitationfortheTinettiBalanceAssessmentTool:

TinettiME,WilliamsTF,MayewskiR,FallRiskIndexforelderlypatientsbasedonnumberofchronicdisabilities.AmJMed1986:80:429-434

• Resource:ThislinksdirectsyoutotheBergBalanceScale:

http://www.aahf.info/pdf/Berg_Balance_Scale.pdfPart2.5.8:PharmacogenomicsPharmacogenomicsisafieldofresearchfocusedonunderstandinghowgenesaffectindividualresponsestomedication.Thelong-termgoalofthisresearchistohelpselectindividualizedappropriatedrugsanddosages.Therearecurrentlymorethan150medicationsthathavepharmacogenomicinformationincludedontheirlabels.

• Resource:ThislinksdirectsyoutotheNationalInstitutesofHealth(NIH)pharmacogenomicdosingguidelines:https://www.pharmgkb.org/view/dosing-guidelines.do

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• Resource:ThislinksdirectsyoutoafrequentlyaskedquestionspageontheNational

InstituteofGeneralMedicalSciencespage:https://www.nigms.nih.gov/education/Pages/factsheet-pharmacogenomics.aspx

MedicationSafetyduringTransitionsofCare:ClinicalImplicationsSection2.6:ToolstoImproveTransitionsofCareProcessesThissectionisdividedinto5Parts:

• Part2.6.1:CareTransitionsTools• Part2.6.2:MedicationReconciliationTools• Part2.6.3:MedicationManagementTools• Part2.6.4:DeprescribingTools• Part2.6.5:RiskScreeningTools

Part2.6.1:CareTransitionsToolsNationalTransitionsofCareCoalition(NTCC)TheNationalTransitionsofCareCoalition(NTCC)acknowledgesthecomplexityoftransitionsofcare.Poorly-definedresponsibilitiesandineffectivepatienthand-offsbetweencaresettingscanpoorlyimpactcaredeliveryduringthisvulnerabletime.Pooroutcomesmayinclude:wrongtreatment,delayindiagnosis,severeadverseevents,patientcomplaints,increasedhealthcarecostsandincreasedlengthofstay.NTOCCcreatedmanytoolsforhealthcareprofessionalstousetoimprovetransitionsofcarewithinanycaresetting.

• Patientmedicationlisto Helpspatientsandcaregiverskeepprovidersinformedofmostup-to-date

medicationlist• PatientBillofRightsduringtransitionsofcare

o Outlinesinformationandservicespatientsdeserve• “TakingCareofmyHealthcare”consumertool

o Guidespatientsandcaregiversonwhatkindofinformationandquestionstoaskproviders

• Informationalslidedeckandbrochureforconsumerso SummarizeswhattransitionsofcareisandwhatNTCCtoolsareavailable

• Implementationplano Outlinestheconcepts,processand"howto"onimplementingandevaluatinga

TransitionsofCareplan

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• Transitionsofcarechecklisto Helpsenhancecommunicationamonghealthcareproviders,betweencare

settings,andbetweencliniciansandclients/caregivers• Importanceofhealthinformationtechnology(HIT)

o IdentifiesHITproblemsandconsiderationstoimproveoveralltransitionsofcare• Medicationreconciliationessentialelements

o Outlinesimportantconsiderationswhenimplementingamedicationreconciliationprogramtoreducemedicationerrors

• PolicypaperandIssueBriefso DetailsvisionofNTCCtoimprovetransitionsofcareandguidanceforimproving

transitionperformance• Culturalcompetencypaper

o providesinformationaboutculture,culturalcompetence,andstrategiesandresourcestoenhanceprofessionals’capacitytodeliverculturallycompetentservices

SomeofthesepracticaltoolsarealsoavailableinSpanishorFrenchtranslations.

• Resource:ThislinkdirectsyoutotheNTCCtoolsandresourcesavailablefordownload:http://ntocc.org/WhoWeServe/HealthCareProfessionals.aspx

InterventionstoReduceAcuteCareTransfers(INTERACT®)InterventionstoReduceAcuteCareTransfers(INTERACT®)isaqualityimprovementprogramthatincludesclinicalandeducationaltoolstohelppost-acutecareprovidersmanageacutechangeinpatientconditionsandpreventavoidabletransferstothehospital.INTERACT®toolsarecurrentlyavailableforNursingHomes,AssistedLiving,andHomeHealthCarepracticesettings;comingsoonisaversionforACOsHealthSystemsandBundledPayment.Thesesite-specificclinicalandeducationtoolsinclude:

• Qualityimprovementtools• Communicationtools• Decision-supporttoolsforchangeincondition• Advancecareplanningtools

• Resource:Usersarerequiredtocompleteafreelicenseagreementtoaccessthese

tools.ThislinkdirectsyoutotheINTERACT®toolsavailablefordownload:http://www.pathway-interact.com/interact-tools/

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AtlanticQualityImprovementNetwork(AQIN)CareCoordinationInitiativeToolsforPatientsAtlanticQualityImprovementNetwork(AQIN)CareCoordinationInitiativecollectednumeroushelpfultoolsforpatientsandcaregiverstouseduringtransitionsofcare.Theseinclude:

• PersonalHealthRecord(alsoavailableinSpanish)o Formtorecordhealthhistory,medicalconditions,medications,allergies,and

recenthospitalanddoctorvisits• MedicationManagementGoldenRules

o Tipstounderstandandkeeptrackofcurrentmedicationsandchangesmade• AskMe3

o Threekeyquestionsforpatientstoaskproviderswhenreceivingcare• HospitalDischargePlanningGoldenRules

o Tipstocommunicateandstayinvolvedindischargeplanning• ManagingYourCongestiveHeartFailure

o Importantheartfailurefacts

• Resource:ThislinkdirectsyoutotheAQINCareCoordinationInitiativepatienttools: http://atlanticquality.org/initiatives/care-coordination/care-coordination-ny/

IHISTateActiononAvoidableRehospitalizations(STAAR)InitiativeTheIHISTateActiononAvoidableRehospitalizations(STAAR)Initiativewasafour-yearmulti-stateapproachtoimprovetransitionsofcareandreduceavoidablerehospitalizationsthroughfourkeyimprovementareas:

• Performanenhancedassessmentofpost-hospitalneeds• Provideeffectiveteachingandfacilitateenhancedlearning• Providereal-timehandovercommunications• Ensuretimelypost-hospitalcarefollow-up

HelpfultoolsontheIHIsiteinclude:

• STAARoverviewdocuments• How-toguidescustomizedforhospitaltocommunitysettings,hospitaltoSNF,hospital

tohomehealthcare,andhospitaltoclinicalofficepractice• Diagnosticworksheets• Statepolicymakerchecklist• Issuebriefs,webinars,presentations,andvideos

• Resource:ThislinkdirectsyoutotheIHISTAARInitiativetools:

http://www.ihi.org/Engage/Initiatives/Completed/STAAR/Pages/Materials.aspx

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Re-EngineeredDischarge(RED)ToolkitTheRe-EngineeredDischarge(RED)ToolkitwasdevelopedtheBostonUniversityMedicalCenter(BUMC)inconjunctionwiththeAgencyforHealthcareResearchandQuality(AHRQ).REDiseffectiveatreducingreadmissionsandposthospitalemergencydepartmentvisits.Contentsofthisexhaustivetoolkitincludehow-toguidesfor:

• 11stepsforhospitalstoimplementRED• TheAfterHospitalCarePlan• DeliveringREDfordiversepopulations• Post-dischargefollow-up• Monitoringimplementationandoutcomemeasures• Enhancetheroleoffamilycaregivers

• Resource:ThislinkdirectsyoutotheAHRQREDtools:

https://www.ahrq.gov/professionals/systems/hospital/red/toolkit/index.htmlPart2.6.2:MedicationReconciliationToolsInstituteforHealthcareImprovement(IHI)MedicationReconciliationContentTheInstituteforHealthcareImprovement(IHI)offersguidanceonprovidingmedicationreconciliationatalltransitionpointstopreventmedicationerrorsthatmayleadtoadverseeventsandharm.IHIdefinesmedicationreconciliationas:“theprocessofcreatingthemostaccuratelistpossibleofallmedicationsapatientistaking…andcomparingthatlistagainsttheadmission,transfer,and/ordischargeorders.”Thegoalofmedicationreconciliationistoensurethatthepatientisreceivingallthecorrectmedicationsandtopreventunintendedchangesoromissionsofmedications.Recommendedchangesforimprovementofmedicationreconciliationprocessesatalltransitionpointsinclude:

• Reconcileadmissionorderswithhomemedicationlistsonadmissiontothehospital• Reconcilemedicationorderswiththemedicationstheyweretakingpriortoadmission

whenpatientsaretransferredfromonecareunittoanother• Reconciledischargeinstructionsandprescriptionswiththemedicationlistcollectedat

admissionandthemedicationadministrationrecord

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Inadditiontotheserecommendations,otherfeaturedcontentonthispageinclude:

• How-toGuide:PreventAdverseDrugEvents(MedicationReconciliation)—RuralHospitalsSupplement

o DevelopedaspartofIHI's5MillionLivesCampaigno Recommendations,implementationandfollow-upmeasuresspecificallytailored

forruralhospitals• MedicationReconciliationReview

o FromtheMayoHealthSysteminEauClaire,Wisconsin,USAo How-to-guideprovidingstep-by-stepinstructionsforhowtoconductareviewto

identifydiscrepancies• MedicationReconciliationFlowsheet

o FromtheMayoHealthSysteminEauClaire,Wisconsin,USAo Tooldesignedfornursestocompletewhilereviewingmedicationorderson

admissionandhelpdeterminenextstepswhenanunreconciledmedicationisidentified

• MedicationReconciliationReview:DataCollectionFormo FromtheMayoHealthSysteminEauClaire,Wisconsin,USAo Anothertoolusedtoaggregateandmonitormedicationreconciliationovertime

asanongoingqualityimprovementeffort• MedicationReconciliationForm

o FromtheBaptistMemorialHospital,Memphis,aparticipantintheIHI’sReducingHighHazardAdverseDrugEventsBreakthroughSeriesCollaborative

o Tooldesignedtotrackapatient’smedicationsuponadmission,transfer,anddischargetodecreasetherateofunreconciledmedications

• MedicationSafetyReconciliationToolkito FromtheNorthCarolinaCenterforHospitalQualityandPatientSafety

• Resource:ThislinkdirectsyoutoIHI“ReconcileMedicationsatAllTransitionPoints”:

http://www.ihi.org/resources/Pages/Changes/ReconcileMedicationsatAllTransitionPoints.aspxFreeloginisrequiredtodownloadtoolsonIHIsite.

IHIalsorecommendschangesforimprovementofmedicationreconciliationprocessesinoutpatientsettings:

• Collectandreconcileamedicationlistateachvisitinoutpatientsettingsandhospital-basedclinics

• Includeallmedications(prescriptions,over-the-counter,herbals,supplements,etc.)withdose,frequency,route,andreasonfortaking

• Verifywhetherthepatientisactuallytakingallmedicationsasprescribed• Ifanymedicationchangesaremadeasaresultofthevisit,givethepatientclear

instructiononwhattodoandwhatfollow-upisrequired• Keepanongoingmedicationlistonfileforrecurringoutpatients

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Inadditiontotheserecommendations,otherfeaturedcontentonthispageinclude:

• MedicationListforPatientsandFamilieso FromtheMassachusettsCoalitionforthePreventionofMedicalErrors(in

collaborationwiththeMassachusettsMedicalSociety)• MyMedicationLog

o FromtheNewYorkCityDepartmentofHealthandMentalHygiene(DOHMH),BureauofChronicDiseasePreventionandControl

• Resource:ThislinkdirectsyoutotheIHI“ReconcileMedicationsinOutpatientSettings”

page:http://www.ihi.org/resources/Pages/Changes/ReconcileMedicationsinOutpatientSettings.aspxFreeloginisrequiredtodownloadtoolsonIHIsite.

HealthIT.govMedicationReconciliationEHRMeaningfulUseMeasureHealthIT.govsetsmeaningfulusemeasurestohelpprovidersimplementelectronichealthrecords(EHRs).TohelphealthcareprofessionalsmeettheMedicationReconciliationmeaningfulusemeasure,acollectionofresourcesandtoolsareavailabletohelpperformmedicationreconciliationatcaretransitions.SelectreferencesfromCMSandtheNationalLearningConsortiuminclude:

• CMSEHRMeaningfulUseSpecificationSheetforEligibleProfessionalsMedicationReconciliation

• MeaningfulUseCaseStudieso FromtheHealthInformationTechnologyResourceCenter(HITRC)o CaseStudiesthatdescribeproviderexperiencesandlessonslearnedthroughout

EHRimplementationandmeaningfuluse• MedicationReconciliationTool

o FromtheHealthInformationTechnologyResourceCenter(HITRC)o Guideincludingself-assessmentandprocessmodelforhowtomeettheMedical

Reconciliationmeaningfuluse• MedicationDiscrepancyTool(MDT)

o FromTheCareTransitionsProgram,UniversityofColoradoDenver,SchoolofMedicine

o Toolthathelpsidentifyandcharacterizemedicationdiscrepanciesthatarisewhenpatientsaretransitioningbetweencaresettings

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• HowtoCreateanAccurateMedicationListintheOutpatientSettingthroughaPatient-

CenteredApproacho FromConsumersAdvancingPatientSafety(CAPS),AuroraHealthCareo Guidanceforimplementingapatient-centeredapproachtomedicationsafetyin

theoutpatientsetting

• Resource:ThislinkdirectsyoutotheHealthIT.govmedicationreconciliationmeaningfuluseresources:https://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/medication-reconciliation

NorthCarolinaCenterforHospitalQualityandPatientSafetyMedicationSafetyReconciliationToolKitTheNorthCarolinaCenterforHospitalQualityandPatientSafetyMedicationSafetyReconciliationToolKitisanextremelyusefulanddetailedtoolincludedasaresourceonboththeIHIandHealthIT.govreferencesabove.ThisToolKitincludesintroductorymaterialsdetailingthescopeoftheproblemofpoormedicationreconciliationprocesses,particularlyduringtransitionsofcare.TheToolKitthenoutlinesprocessstepstoestablishandimplementamedicationreconciliationprocessandincludessampleprocessmaps,algorithms,andformswhichcanbeusedtodevelopperformanceimprovementmodel.Severalreferences,websitesandexampleprocessesarecitedattheendforfurtherinformation.

• Resource:ThislinkdirectsyoutotheMedicationSafetyReconciliationToolKit:http://www.ncqualitycenter.org/wp-content/uploads/2013/01/MRToolkit.pdf

Part2.6.3:MedicationManagementToolsAmericanMedicalAssociation(AMA)STEPSForwardMedicationAdherenceModuleTheAmericanMedicalAssociation(AMA)STEPSForwardreleasedaMedicationAdherenceModule.Thisonlinemodulecanbecompletedfor0.5CMEanddownloadabletoolsarealsoavailable.Themoduledefinesmedicationnonadherence,howcommonitis,andwhyitisimportanttoaddressbeforeoutliningthefollowingeightstepstoimprovemedicationadherence:

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• Considermedicationnonadherenceasthefirstreasonapatient'sconditionisnotunder

control• Developaprocessforroutinelyaskingaboutmedicationadherence• Createablame‑freeenvironmenttodiscussmedicationswiththepatient• Identifywhythepatientisnottakingtheirmedicine• Respondpositivelyandthankthepatientforsharingtheirbehavior• Tailortheadherencesolutiontotheindividualpatient• Involvethepatientindevelopingtheirtreatmentplan• Setpatientsupforsuccess

Thereaderwillfindtipstoinvolvestaffandpatientsinidentifyingnonadherenceandchangingbehaviors.

• Resource:ThislinkdirectsyoutotheAMAMedicationAdherenceModule:https://www.stepsforward.org/modules/medication-adherence

HealthcareCompliancePackagingCouncil(HCPC)WhitePaperTheHealthcareCompliancePackagingCouncil(HCPC)promotesthebenefitsofunitdosepackagingwithcompliance-promptingfeaturestohelppeopletaketheirmedicationsproperly.TheHCPCreleasedaWhitePaperonImprovingMedicationAdherenceThroughPackaging.ThisWhitePaperdefined“medicationadherence”astheextenttowhichpatientsfollowproviderrecommendationsaboutday-to-daymedicationswithrespecttothetiming,dosage,andfrequency.Theresultsofninestudiesaresharedthatsupporttheirposition.Compliancepackaging(i.e.calendar-oriented,unit-dose,structured,blisterpackaging,remindercards)resultsindecreasedconfusionandmisunderstandingandincreasedadherenceandcompliance.

• Resource:ThisisthecitationfortheHCPCWhitePaper:ImprovingMedicationAdherenceThroughPackaging.HealthcareCompliancePackagingCouncil.Availableat:http://www.hcpconline.org/.AccessedAugust18,2017.

GuideforIdentifyingandResolvingDischargeMedicationAccessibilityProblemsinNewYorkStateTheAtlanticQualityImprovementNetwork(AQIN)QualityImprovementOrganization(QIN)forNewYorkState,SouthCarolina,andtheDistrictofColumbiaprepareda“GuideforIdentifyingandResolvingDischargeMedicationAccessibilityProblemsinNewYorkState”whichoutlinespotentialproblemsandguidanceforresolutiontohelpidentifypotentialdrugtherapyandcommunitypharmacyproblems

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• Resource:ThislinkdirectsyoutotheAQINmedicationaccessibilityproblemsguide:

http://atlanticquality.org/wp-content/uploads/2016/05/508_Doc3-_NYS_Guide_-Access_Problems.pdf

OptimizingDischargeMedicationListsInastudybyBackesetalpublishedinTheConsultantPharmacist,aneedsassessmentperformedcaretransitionspharmacistidentifiedopportunitiestooptimizedischargemedicationlistsinskillednursingfacilities.Thegoalofthispilotstudywastoincreasepatientsafety,reducemedicationerrorsandpreventmedication-relatedhospitalreadmissionsthroughoptimizationofdischargemedicationlists.SomeidealcomponentsofaskillednursingfacilitydischargemedicationlistlistedinTable1include:

• Generateanelectroniclisttominimizehumanerrorrisk• Listbothbrandandgenericmedicationnames• Avoidusingsigcodesandmedicalabbreviations• Provideindicationsforallmedicationsinlaypersonterms• Determineifholdparametersareappropriateandunderstoodbypatientand/or

caregiver• Eliminateunnecessaryprotocolmedications• Considerfontsizeandlayouttomaximizereadability

• Resource:Thisisthecitationforthedischargemedicationlistspilotstudy:

BackesAC,CashP,JordanJ.Optimizingtheuseofdischargemedicationlistsinnursingfacilities.ConsultPharm2016;31:493-9.

Part2.6.4:DeprescribingToolsCanadianDeprescribingNetwork(CaDeN)DeprescribingToolsTheCanadianDeprescribingNetwork(CaDeN)createdseveraldeprescribingguidelinesforreducingorstoppingpotentiallyunnecessaryorharmfulmedications.Theseguidelinestargetthefollowingclassesofmedications:antipsychotics,benzodiazepinesandZ-drugs,protonpumpinhibitors,antihyperglycemics,andantihistamines.Resourcesavailablefordownloadinclude:guidelines,algorithms,informationpamphlets,andlinkstoseveralhelpfulpolypharmacyanddeprescribingresources.Patientdecisionaidsarecomingsoon.

• Resource:ThislinkdirectsyoutotheCaDeNdeprescribingtoold:http://deprescribing.org/resources/

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MedStopperMedStopperisaninteractivewebsitewheretheusercaninputlistsofmedicationsandtheconditionsforwhichmedicationsareusedtogeneratealistofpotentiallyinappropriatemedicationsthatmaybedeprescribed.TheMedStopperPlandisplaysthemedicationsinorderofstoppingprioritywithREDsignifyingthehighestpriority,andGREENthelowestpriority.ThisPlancanbeprinted.Recommendationsfordrugstostoptakeintoconsideration:

• Frailelderlyscale• Potentialforimprovingsymptomsorreducingriskforfutureillnessorcausingharm• WhetheronBeersorSTOPPcriteria• Whethertaperingissuggested

• Resource:ThislinkdirectsyoutotheinteractiveMedStopperwebsite:

http://medstopper.com/GoodPalliative-GeriatricPracticeAlgorithmTheGoodPalliative-GeriatricPracticealgorithmwasdesignedfornursinghomestoreducepolypharmacy.Aseriesofquestionsdeterminewhetherdrugsshouldbecontinuedatthesamedose,reducethedose,stopthedrug,orswitchtoanotherdrug.Thealgorithmassessesif:

• Indicationisvalidandrelevant• Possibleadversereactionsoutweighpossiblebenefits• Drugcausingadversesignsorsymptoms• Anotherdrugissuperior• Dosecanbereducedwithoutsignificantrisk

WhentestedinnursinghomesinIsrael,thealgorithmreducedmortality,hospitalization,andcostwithlowrateofdrugdiscontinuationfailure.

• Resource:ThisisthecitationfortheGoodPalliative-GeriatricPracticealgorithm:GarfinkelD,Zur-GilS,Ben-IsraelJ.Thewaragainstpolypharmacy:anewcost-effectivegeriatric-palliativeapproachforimprovingdrugtherapyindisabledelderlypeople.IsrMedAssocJ2007;9(6):430–4.

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PrioritizationandStoppingMedicationsIn“PrioritizationandStoppingMedications”,Alexanderetal.outlineopportunitiesforprioritizationordiscontinuationofmedicationsbasedondegreeofuncertaintyandreasonforaction.Medicationsmaybediscontinuedwithnoneorminimaluncertaintytocorrectamedicalerror,tosimplifyregimen,whenclinicalbenefitisunlikely,orwhensafeforuseonanas-neededbasis.Withmoderatestakes,adrugdiscontinuationtrialisappropriatebecausebenefithaslikelybeenachieved,abehavioralinterventioncanbesubstituted,orbenefitisunlikelytoberealized.Withhighstakes,carefulprioritizationisnecessary.Real-worldexamplesofpatientsareprovidedforeachriskscenarioabove.

• Resource:Thisisthecitationfortheprioritizationandstoppingmedicationsarticle:AlexanderC,etal.Prioritizingandstoppingprescriptionmedicines.CanadianMedicalAssociationJournal.2006;174(6):1083-4.

MedicationAppropriatenessforPatientsLateinLifeIn“ReconsideringMedicationAppropriatenessforPatientsLateinLife”,Holmesetal.proposedamodelforappropriateprescribingforpatientslateinlifethatconsiders:

• Remaininglifeexpectancy• Timeuntilbenefitwillbeachieved• Goalsofcare• Treatmenttargets

Thegoalofthismodelistoserveasaguidefordiscontinuationorwithholdingoftreatmentsotherwiseindicated,appropriateandrecommendedaccordingtocurrentguidelines

• Resource:Thisisthecitationforthemedicationappropriatenesslateinlifearticle:

HolmesH,etal.Reconsideringmedicationappropriatenessforpatientslateinlife.Archivesofinternalmedicine.2006;166(6):605-9.

Part2.6.5:RiskScreeningToolsTheLACEIndexTheLACEIndexisascoringtoolthatidentifiespatientsathighriskforreadmissionordeathwithin30daysofdischargefromhospital.LACEscoresrangefrom1-19.Ascoreof0–4=Low;5–9=Moderate;andascoreof≥10=Highriskofreadmission.

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LACEstandsfor:

• “L”=lengthofstay• “A”=acuityofadmission(i.e.throughtheEmergencyDepartmentvs.elective

admission)• “C”=co-morbidities• “E”=EmergencyDepartmentvisitswithinthelast6months

ThisIndexcanhelppharmaciststargetandprioritizepatientswhowouldbenefitmostfrommedicationreconciliationandeducationontransition

• Resource:ThislinkdirectsyoutotheLACEindex:http://www.besler.com/lace-risk-score/