Medication Safety

1. Medication Safety The Role of Medication Reconciliation & Medicine Lists Presenter Name & Organization

2. Objectives • Be familiar with Washington Patient Safety Coalition • Understand where medication reconciliation, My Medicine List, and safe transitions fit into the medication safety strategic plan. • Understand the current regulatory drivers around medication reconciliation, such as The Joint Commission’s National Patient Safety Goal (NPSG) • Advocate and implement medication reconciliation into workflow • Promote patient awareness and utilization of My Medicine List

3. Patient Case • 52 year old man goes to the clinic for a check-in visit with his Specialist provider. • Patient’s electronic chart indicated he was to take 1 tablet of aspirin 325 daily. Patient reported taking 18 tablets of aspirin 325mg daily for shoulder pain. • This is almost 6,000 mg of Aspirin • New pain regimen was discussed

4. The Washington Patient Safety Coalition is dedicated to improving patient safety and reducing medical errors for individuals receiving health care in Washington, in all care settings. About the WPSC www.wapatientsafety.org

5. The Concerns Around Medication Safety • 1999 IOM report: estimated that medical errors cause 44,000 to 98,000 preventable deaths and one million additional injuries each year in U.S. hospitals, and cost over $850 billion. • A 2006 follow-up to the IOM study found that medication errors are among the most common medical mistakes, harming at least 1.5 million people every year. According to the study, each year… • 400,000 preventable drug-related injuries occur in hospitals • 800,000 in long-term care settings • 530,000 among Medicare recipients in outpatient clinics

6. Improving Medication Safety: Where to begin? Drug Interactions High Alert / High Risk Agents Adherence/ Compliance Barriers Patient Education Improved Packaging & Labeling Medication Errors Prescriber Education Transitional Care Management Transitional Care Management

7. Patients at Risk Nearly 40% of patients have ≥ 1 unintended medication discrepancy at hospital admission! A similar proportion are present at transfer within a hospital and in 14% of patients at hospital discharge. Cornish PL et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165:424-429.

8. Medication Reconciliation: A Definition? No standard exists! The Joint Commission recommends… The process of verifying that a patient’s current list of medications (including dose, route, and frequency) is correct and that the medications are currently medically necessary and safe. Greenwald et al. Making inpatient medication reconciliation patient centered, clinically relevant, and implementable: a consensus statement on key principles and necessary first steps. JtComm J Qual Patient Saf. 2010 Nov;36(11):504-13, 481.

9. Medication reconciliation should be a patient-centered process, taking into account the patient’s level of health literacy and willingness to engage in his or /her personal health care. Target improvement in patient well-being through education, empowerment, and active involvement Achieve by promoting communication among patients and healthcare providers ASHP-APhA Medication Reconciliation Goals ASHP – APhA Medication Reconciliation Initiative Workgroup Meeting . February 12, 2007

10. Achieving Medication Safety Goals via Medication Reconciliation Drive Systems (Re)Design and Process Improvement Drive Systems (Re)Design and Process Improvement • Catalyst Driving Change • WPSC • Regulatory Organizations • Reimbursement Models Maximize Use of Technology Facilitate Cultural Change

11. Healthcare Systems Design:Must Support the Med Rec Process Collect Clarify • Change in… • Care Setting • Medications Verify Reconcile Communicate Educate

12. Medication Reconciliation: Not So Simple! DISCHARGE PROCESS COMMUNITY PROCESS HOSPITAL ADMISSION PROCESS Medication Info Sources Pt & Family Clarification/Verification Physicians Pre-Admit Outpt Medication List Pre-Admit Outpt Medication List Pre-Admit Outpt Medication List Pharmacies Pt & Family Care Facilities Physicians Outpatient Medication List Pharmacies Medical Records Inpatient Med List Inpatient Med List Care Facilities 3rd Party Vendors Discharge Medication Reconciliation Patient condition & diagnosis

13. Real Life Example: Inpatient Admission Patient admitted through ED ED Not a good setting for collecting information Triage, stabilize, transfer or discharge Solution: ED Med Rec Techs Complete when admitted on unit? Nurses busy admitting patient Med Rec challenging and time consuming Use what was collected in ED? Verify but not thoroughly? Provider prints off what is in system Unverified, from last admission Errors perpetuated on Transfer and at Discharge Garbage In = Garbage Out

14. Real Life Example: Franciscan Health System Patient Arrives at ED ED Med Rec Tech Interviews patient or caregivers Records medication information from patient medication bottles Calls outpatient pharmacies, queries available sources, GH Epic, FMG Elysium, etc., contacts patient’s PCPs Clarifies information with family or caregiver Generates a complete and accurate home med list that is reviewed by a pharmacist List provided to ED or admitting provider to complete medication reconciliation. Accurate home medication improves transitions in care Provides a good foundation for Discharge Med Rec

15. Real Life Example: Group Health Post-Discharge Medication Reconciliation Primary Care Discharge Home • Pharmacist updates patient’s physician • Makes medication • recommendations • Patients identified who are high risk for readmit • Information sent to Clinical Pharmacists for follow up • Pharmacist calls patient 1 - 3 days post-discharge • Med recon and comprehensive medication review 80% of patients have at least one discrepancy resolved.

16. Safe Transitions Involve Many! Safe transitions are best when we maximize a multi-disciplinary approach Group Health: Specialty Medication Reconciliation involves a variety of disciplines Medical Assistant: medication verification Specialist: medication review and hand-off to pharmacist Pharmacist: comprehensivemedication reconciliation and communication to patient and appropriate physicians Primary Care Provider: authorize prescriptions and carry out ongoing care of patient’s therapy

17. Mandating change and prioritization Technology Adoption Incentivizing Change via Regulatory Process

18. The Joint Commission Medication Reconciliation Requirements A 6-year journey to improve patient safety 2005 2006 2007 2008 2009 2010 2012 • TJC • introduces • NPSG 8 • “Med Rec” required for accreditation • NPSG • minor revisions • NPSG major revisions planned • Scoring suspended and some simplification • New standards created & released • Implementation of new standard

19. TJC 2011 Medication Reconciliation National Patient Safety Goal #3: “Improve the safety of using medications” NPSG.03.06.01:“Maintain and communicate accurate patient medication information” • Applies to: • Hospitals, including Critical Access Hospitals • Ambulatory Care • Office (Ambulatory) Surgery • Home Care • Long-term Care • Behavioral Health

20. The Patient Protection and Affordable Care Act (H.R. 3590) Value-Based Purchasing (VBP) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) (Section 3001) Core Measures (Section 3001) Healthcare-Associated Infections (HAI) (Section 3001) At Risk: 1% in FY2013 growing annually to 2% in FY2017 (70% Core Measures + HAI and 30% HCAHPS) Medicare Reimbursement At Risk: 1% reduction beginning FY2015 At Risk: 1% reduction in FY2013 and will Rise to 3% by FY2015 Hospital Acquired Conditions (HAC) (Section 3008) Readmission Rates (Section 3025) AMI, PNE, HF COPD, CABG, PTCA, etc. 5

21. Readmissions are… Medications and medication use are often implicated in unexpected readmissions! http://www.medpac.gov/documents/jun07_entirereport.pdf MedPAC 2007 Report to Congress; Promoting Greater Efficiency in Medicare Frequent • 18% of all Medicare hospitalizations are 30-day re-hospitalizations • Average rates are >20% for certain patient populations Potentially avoidable • 76% of Medicare re-hospitalizations were “potentially preventable” Costly • $15B annually in Medicare of which $13B may be unnecessary Actionable for improvement • Research and quality improvement initiatives have demonstrated >30% reduction of 30-day readmission rates for a variety of populations

22. Med Reconciliation & Readmissions How much does a hospital readmit cost? $14,500 Our analysis shows that for every 25 patients that receives med recon post- discharge, 1 hospital readmit is prevented. For the 2012 calendar year, the program will save an estimated 1 million dollars 14 day 30 Day Kilcup M, Schultz D, et al. Post-discharge pharmacist medication reconciliation: Impact on readmission rates and financial savings. J Am Pharm Assoc. 2013: Jan/Feb, 53:1.

23. Opportunities for Pharmacy: Readmissions Preventing Interventions Phase of Care Admission Inpatient Stay Discharge Home Pharmacy Service Provided • Perform Admission Assessment • Determine factors in admission/readmission • Medication history • Medication reconciliation • Errors of omission (EBM) • Adverse drug events (ADE) • Medication adherence • Medication access • Determine post-hospital needs • Where will patient likely receive care? • Who are caregivers? • Barriers to care? • Care Optimization • Provide effective teaching & enhanced learning • Identify barriers to learning • Medication management • Disease self-management • Medication adherence • Use “Teach Back” method • Provide tools • Optimize the medication regimen • Initiate indicated medications • Discontinue unnecessary or unsafe medications • Simplify the medication regimen • Prepare for Transition in Care • Medication regimen review • Medication reconciliation • Provide medication list and related information to: • Patient/caregiver • Physician/medical team • Pharmacy/pharmacist • Verify appropriate post-discharge care plan • Match discharge follow-up to need (readmission risk stratification) • Ensure proper information is provided regarding contact information, action plan for care and symptom or AE management • Provide Appropriate Post-Discharge Care • Contact patient/caregiver • Live or virtual visit • Patient status and medication review • Medication reconciliation • Medication adherence • ADE surveillance • Medication access • Med management/ Disease management • Communicate to other providers any pertinent medical information or findings

24. Achieving Medication Safety Goals via Medication Reconciliation Drive Systems (Re)Design and Process Improvement • Catalyst Driving Change • WPSC • Regulatory Organizations • Reimbursement Models Maximize Use of Technology Maximize Use of Technology Facilitate Cultural Change

25. Achieving Medication Safety Goals via Medication Reconciliation Drive Systems (Re)Design and Process Improvement • Catalyst Driving Change • WPSC • Regulatory Organizations • Reimbursement Models Maximize Use of Technology Facilitate Cultural Change Facilitate Cultural Change

26. A WPSC Sponsored Project “My Medicine List”

27. My Medicine ListHeighten Public Awareness Emphasize the need for patients to take an active role in managing their medicines. The initiative’s goal is for every person to maintain an up-to-date list and to share it with his/her health care provider.

28. My Medicine List

29. What's in a “Medicines” List • Respiratory therapy-related medications • Parenteral nutrition • Blood derivatives • Intravenous solutions (plain or with additives) • Diagnostic and contrast agents • Radioactive medications • Prescription medications • Sample medications • Vitamins • Herbal & Alternative Meds • Nutriceuticals & Dietary Supplements • Over-the-counter drugs • Vaccines Any product designated by the FDA as a drug!

30. How Can You Help?Remember the 3 As Refer your patients to mymedicinelist.org for information and resources What you don’t know about your patients could harm them! ASK every patient about his or her medicine list at each encounter. ADVISE your patients to carry a list ASSIST your patients with resources & tools

31. Thank You!