Exploring the Roles in Medication Management Provider, Nurse, Pharmacist and Patient

1. Exploring the Roles in Medication ManagementProvider, Nurse, Pharmacist and Patient Salahuddin Kazi, MD Eric Spahn, Pharm D Tammy Rosenberger BSN, RN Michael Bingham, CPhT

2. The Role of Nurses in Medication Management Tammy Rosenberger BSN, RN

3. Nursing’s role • Nurses have played a major role in patient safety for years. • Florence Nightingale • Clara Barton • Linda Richards

4. Nursing and medication safety • Nurses have the opportunity to keep the patient safe from harm when it comes to their medication. • Before the pt is seen by the provider, during prevention and completion of clinical reminders, ask if there are any additions or changes in medication • If the pt has reminders re: chronic disease, this can alert the nurse to discuss current medications for these conditions. • Include asking about non-va meds (herbals, OTC, prescribed meds by other providers outside the VA system) • Nurses have the ability to enter and remove them. • Can also document changes on check in sheet to alert provider. • When a patient is calling for changes or new meds from outside provider. • Discharge f/u calls • Seeing patient after visit to offer education

6. Nursing and medication safety Is the pt taking b/p meds; when was last dose; taking regularly;

7. Nursing and medication safety • BCMA – Bar Code Medication Administration • Idea of Sue Kinnick, RN -1994 –Eastern Kansas Health Care System

8. Nursing and medication safety • Case manager – 1200 patients • PACT model: High risk registry • Visit includes medication reconciliation • Med list • Active meds, any non va meds, • Encourage patient to bring in prescription bottles • Alert provider to discrepancies • Allergies • Review and document, alert provider

9. Upcoming Med safety project • Pilot project at Pittsburgh • Medication review will be available for the pt on the Kiosks. • Pictures of the pills will be shown, pt will be able to choice which pill they have if manufactures are changed • Staff will be available to assist patients with this process. Improves the process for patients to be better prepared to see their provider.

10. Kiosk Display

11. The Provider’s Role in Medication Management Salahuddin Kazi, MD

12. The Physician Visit • Embed medication reconciliation within the workflow of the visit and NOT as a separate process • Discuss medications as part of disease management • View remote meds • Review Allergies • Review pharmacist flags • Confirm indications, strength and indications • Review interactions • Assess appropriateness of therapy • Educate the patient and provide a written list of medications

14. Clinicians are busy!

15. The Clinician’s Perspective: Visit For Diabetes

16. Workflow

17. Three Pronged Approach to Medication Reconciliation

21. The After Visit Summary

22. After Visit Summary http://ixblog.wordpress.com/ix-reports/the-after-visit-summary-avs/

23. Timing is everything!

24. After Visit Summary LOCAL TITLE: RHEUMATOLOGY AFTERVISIT SUMMARY STANDARD TITLE: MEDICATION MGT NOTE DATE OF NOTE: APR 25, 2012@09:07 ENTRY DATE: APR 25, 2012@09:07:53 AUTHOR: Provider #1 EXP COSIGNER: URGENCY: STATUS: COMPLETED ***CLINIC AFTERVISIT SUMMARY*** XXXXXXXXXXXXXXXX DOB: XXXXXXXXXXX APR 25, 2012 Thank you for allowing us to participate in your healthcare. Please review and retain this document. It may contain additional information or instructions from your care provider. ________________________________________________________________________ Today your provider was: Provider #1 Primary Care Team: Blue Team #1 Primary Care Doctor: Provider A

25. After Visit Summary Future Appointments: 5/5/12 11:30 am GI LAB SATURDAY 5TH FLOO ext.71590 5/7/12 1:00 pm DIABETES INTRODUCTION ext.74270 7/9/12 1:00 pm XLAB CLINIC-X ext.70678 7/9/12 3:00 pm DALLAS PC CL10 ext.78914 Labs that were ordered today: No pending labs. Imaging studies that were ordered today: NO recent pending Radiology found. Consults or procedures that were ordered today: NO recent pending Consults found.

26. After Visit Summary Your vitals for today are: Blood Pressure - 140/66 (04/25/2012 08:25) Weight - 254 lb [115.5 kg] (04/25/2012 08:25) Pain Level - 5 (04/25/2012 08:25) Allergies: Patient has answered NKA

27. After Visit Summary These are the MEDICATIONS we show you should continue taking: Active Medications ============================================================ 1) Acetaminophen 500Mg Tab Take one tablet by mouth twice a day as needed for pain. Maximum of 3000mg of acetaminophen per day from all sources 2) Allopurinol 100Mg Tab Take one tablet by mouth every day for gout 3) Gemfibrozil 600Mg Tab Take one-half tablet by mouth twice a day for cholesterol 4) Magnesium Citrate 300Ml Bt Take 2 bottles by mouth once drink 2 bottles as directed By gi lab instructions. 5) Polyethylene Glycol,(golyte/colyte) 4L Take 4 liters (1 bottle) by mouth once 6) Prednisone 20Mg Tab Take one tablet by mouth every day for inflammation You have 6 active medications ______________________________________________________________________ Your provider has NOT prescribed any new medications today. _______________________________________________________________________ These are DISCONTINUED medications that you should NO LONGER TAKE: Indomethacin 25Mg Cap Take Two Capsules By Mouth Three Times A Day For Pain

28. After Visit Summary Additional provider instructions: If you get a gout flare, please call clinic. a. Please give a list of these medications to each provider you see. b. You can use this list of medications to update the information when any of these medications are discontinued, doses are changed, or new medications (including over the counter products, herbals and supplements) are added. c. Please carry medication information at all times in the event of emergency situations. _______________________________________________________________________ If you have any questions, please notify an assistant before you leave. If you have questions or concerns after today, please contact the clinic. Please leave a message for the rheumatology nurse at 1-800-849-3597 extension 72105. Your call will be returned in 1 business day. For medication refills please call 1-800-849-3597 extension 79000. After hours and weekends: Registered nurses are available 24 hours, 7 days a week and on holidays to answer medical advice questions by calling 800-677-8289. /es/ Provider #1, RN, MSN, FNP-c RHEUMATOLOGY NP Signed: 04/25/2012 09:09

29. The Pharmacist’s Role in Medication Information Management Eric Spahn, PharmD

30. Access to Care “Pharmacists are the most accessible health care professionals in the United States and have always been one of the most trusted professions.” -2011 USPHS Report to USSG

31. Part of a Team COMMUNICATION

32. Medication Experts

33. Part of Our Job • Interpretation and verification of physician’s orders, patient medication profile review (allergy, drug interaction screens, etc.) providing drug and policy information to patients and medical center staff. • Direct and Indirect patient care, drug therapy monitoring, formulary management, staff education, prescription inputting, patient counseling, and cost containment • Recommend, implement, monitor, and modify patient-specific pharmacotherapy in collaboration with patients and other health care professionals to optimize drug therapy. • Notification of safety and drug alerts (CMOP delays, shortages, recalls, etc.) to patients and providers • Assignment to specific clinical areas including discharge pharmacy, anticoagulation, geriatric medicine, home-based primary care, antibiotic stewardship, behavioral medicine, and other clinical areas.