Discharge Medication Reconciliation and Counseling Pilot

1. Discharge Medication Reconciliation and Counseling Pilot Chris Maxwell, PharmD Director of Pharmacy Nov. 5, 2011

2. National Patient Safety Goal • Joint Commission requirement for 2006 • 8a – Implement a process for obtaining and documenting a complete list of the patient’s current medications upon admission to the organization… • 8b – A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization

3. Reconciliation Process • Develop a list of current meds • Develop a list of meds to be prescribed • Compare the meds on the 2 lists • Make clinical decisions based on the comparison • Communicate the new list to appropriate caregivers and to the patient

4. Reconciliation or Verification? • Medical records • Physicians • Pharmacies • Pill bottles

5. Safe Transitions of Care • Patients bringing significant number of meds into hospital • Meds secured in pharmacy during admission • Meds returned to patient upon discharge • Concern that meds may be duplicative, contraindicated, or inconsistent with discharge instructions

7. Role of the Pharmacist • Pharmacist to assist with Med Recon in Admissions during peak hours • Change in focus of med education from group setting to individual

8. New Process Outline • MD and patient agree on what meds are to be returned or destroyed • Pharmacist evaluates Discharge Instructions and compares with med bottles • Review medication education • Consult MD when necessary

9. Pilot Project Designed • D4, a large Adult Inpatient unit selected • Re design of “Medications Brought into the Hospital” form. • Data collection • Pilot Jan-Mar 2011 • 99 patients

11. Results

12. Results

13. Pilot Data Analysis • A potential medication related problem was identified and corrected in 31% of patients counseled • Resource neutral • Average of 10 minutes face time with patients

14. Future Plans • Discharge Medication Team plans to implement hospital wide • Challenges Ahead • Computerized Physician Medication Management

15. Questions