Medication Communication

1. Medication Communication March 13, 2013 Carrie Brady, JD, MA cbradyconsulting@gmail.com Ashka Dave adave@aha.org David Schulke dschulke@aha.org

2. AHRQ/HRET Patient Safety Learning Network (PSLN) Project • This program is supported by the U.S. Agency for Healthcare Research and Quality (AHRQ) through a contract with the Health Research and Educational Trust (HRET). • HRET is a charitable and educational organization affiliated with the American Hospital Association, whose mission is to transform health care through research and education. • AHRQ is a federal agency whose mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

3. The Patient Experience of Care is Fundamental to Clinical Improvement • Understanding the patient experience of care is not an add-on activity: it should be used as a fundamental element in your other improvement efforts. • For those working on the HRET Partnership for Patients Hospital Engagement Network (HEN) or another HEN, your work will benefit directly from your efforts to improve the patient experience of care (e.g., readmissions, ADEs). • Lessons you learn in this HCAHPS Learning Network will help you succeed in the HEN project because— • Patient-centered care is a driver of clinical outcomes • Employee and patient engagement are 2 sides of one coin • HCAHPS assesses key factors in ADEs and readmissions

4. HCAHPS Technical Assistance Faculty • Carrie Brady, MA, JD • HRET’s primary HCAHPS faculty • Former senior Connecticut Hospital Association staffer • Previously a vice president at Planetree • Exemplary hospital peers • Clarke County Hospital • Recent significant improvements in medication communication • AveraDeSmet Memorial Hospital • Top decile nationally in medication communication

5. One Reason Medication Communication is Important: ADEs a Major Source of HACs Source: AHRQ/CMS data from Medicare Patient Safety Monitoring System, NHSN, PSIs

6. Another Reason: the Stakes for HospitalsPPACA Readmission & HCAHPS Policy in VBP Medicare Readmissions Penalty • Year One: 67% of Hospitals had a penalty; 33% had no penalty. Average hospital penalty: $125,000. • 9% of hospitals were at the maximum penalty cap of 1% (doubles to 2% maximum, more DRGs added in October) • 25% of readmissions attributed to patient non-adherence Medicare Value-based Purchasing (VBP) Incentive Payments • Patient experience of care = 30% of VBP score. ~1/3 of substantive HCAHPS questions now ask about medications and care transitions: • “When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.” • “When I left the hospital, I clearly understood the purpose for taking each of my medications.”

7. HCAHPS Medication Communication Domain • Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? • Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? Source: CMS Summary of HCAHPS Survey Results and HCAHPS Percentiles December 2012 Public Report (April 2011 – March 2012 Discharges) www.hcahpsonline.org • 63% “Always” is the national average • Communication about medicines is the second lowest scoring HCAHPS domain • Quiet is lowest • Best performing hospitals in the country (95th percentile) get 74% or more “Always”

8. Thinking About Medication Communication Consider where the process is breaking down in your organization. Are you: • Failing to understand the patient’s medications? OR • Failing to communicate about medication? OR • Not communicating in an effective way?

9. Professional Knowledge of Patient’s Meds: the Admission Medication Reconciliation • 27% of ALL prescribing errors that occur in the hospital result from incomplete medication histories at the time of admission. • 22% of Discrepancies could have resulted in patient harm during their hospitalization. • 59% of Discrepancies could have resulted in patient harm if the discrepancy had continued as ordered after discharge. Sullivan C, Gleason KM, et al. Medication Reconciliation in the Acute Care Setting: Opportunity and Challenge for Nursing. J Nurs Care Qual2005 Vol 20, No2: 95-98

10. Importance of Medication Reconciliation in Avoiding Readmissions • Carver reports errors in admission med rec tend to be perpetuated in the discharge med rec, sending the patient home with incorrect information, and potentially conflicting medications. • Coleman et al found that hospital readmission rates for patients with identified medication discrepancies were 14.3% among the 375 study patients. This contrasted with a 6.1% readmission rate among patients with no identified medication discrepancy. Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. Sep 12 2005;165(16):1842-1847.

11. Pharmacist-led Admission Medication Reconciliation Improved Accuracy • Pharmacist-recorded Medication Histories result in higher accuracy and fewer medical errors. • Gleason KM, Groszek JM, Sullivan C, et al. Reconciliation of Discrepancies in Medication Histories and Admission Orders of Newly Hospitalized Patients. Am J Health Syst Pharm. 2004;61:1689-1695. • Nester TM, Hale LS. Effectiveness of a pharmacist-acquired Medication History in Promoting Patient Safety. Am J Health Syst Pharm. 2002;59:2221-25. • Yet, pharmacists conduct the medication history only 5% of the time in most US hospitals. • Source: Bond CA, Raehl CL, Franke T. Clinical Pharmacy Services, Hospital Pharmacy Staffing and Medication Errors in United States Hospitals. Pharmacotherapy. 2002; 22:134-147. 11

12. Common Barriers/Sample Solutions: Failure to Communicate • Staff do not know when medication education is necessary • Prompts when a new medication is provided • Staff log of medication education • Staff do not know the side effects of each med • Medication information sheets with each new medication, pharmacy brown bag lunches, routine education with changes in formulary • Peer pressure not to discuss “side effects” • Develop shared expectations of communication • Staff do not know what meds patient is taking • Get help from pharmacist to reconcile medications

13. Sample Solutions: Not Communicating Effectively • Medication education • Printed information for patients (e.g. medication information sheets, daily patient-friendly MAR) • Emphasize why, not just how • Ask patients/family how to do it better • Discharge process and post-discharge phone calls • Teach-back • Verifies patient understanding • Free resources available at www.teachbacktraining.com/ • Engage pharmacist in patient rounding

14. Patient Knowledge of Hospital Medications Study compared hospital MAR to patient list • Overall, patients were able to name less than half of their hospital meds • 96% of patients omitted at least one med; 6.8 meds were omitted on average • 44% of patients believed they received at least one med that wasn’t given • 28% had seen their hospital medication list • 81% said seeing the list would improve their satisfaction with care Cumbler E., Wald H., Kutner J., Lack of Patient Knowledge Regarding Hospital Medications, Journal of Hospital Medicine, 5:2 February 2010.

15. Pharmacist Patient Education Reduced ADEs A randomized trial of 178 patients being discharged home from the general medicine service found pharmacist counseling reduced the number of preventable adverse drug events from 11% in the control group to 1% in the intervention group. Source: Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. Mar 13 2006; 166(5):565-571. 15

16. Medication Communication Case Study Avera De Smet Memorial Hospital De Smet, South Dakota

17. Situation:Communication of Medications Patients who reported that staff “Always” explained about medications before giving it to them. • Avera De Smet Memorial Hospital • 86% • SD state average • 68% • National Average • 63%

18. Background:Our HCAHPS Journey Healthcare Reform and VBP • Develop committee- Co-Chairs include DON and Safety Officer, members rotate • Selected Tool-The HCAHPS Handbook by QuintStuder • Set our plan • Consistent meetings held-rain or shine • We now have done an initial and follow-up meeting for each topic • Next steps: select a focus area

19. Action: Recommendations from book • Use key words to ensure two-way dialogue about medications • Explain each med at each dose • Encourage two-way communication-pause during explanation to allow questions • Use patient friendly terminology-not medical terms/phrases/initials • Always share 6 critical components: name, purpose, duration, when will it take effect, dosage, side effects • Ask for patient’s compliance- “Is there anything that might prevent you from taking this medication when you go home?” • Reinforce education regularly • Use whiteboard to communicate with other staff about medication education • Be consistent • Validate an verify with nurse leader rounding

20. Action continued: 2. Reinforce Medication Education into bedside shift report • Review the printed list of medications with pt and nurse • Highlight medication instructions-literally • Engage the patient in the conversation • Re-explain the medication

21. Actions continued • 3. Make post-visit calls and include medication information • Check on the medication- are new Rx’s filled? • Link back-”remember when the nurses at the hospital would change shifts and review your medicines?” • Use key words that align with the explanation of medication-”what side effects are you watching for” • Have the primary nurses call • Help staff connect these calls back to purpose

22. Response:ADMH recommendations • Explain each med at each dose- name & purpose • Med education required for each first dose • Post hospitalization home visit within 48 hours and 3 phone calls within 30 days • Home visit Confirm F/U appts Review education Reconcile medications • Phone calls Review F/U appts Inquire about new prescriptions Confirm understanding of education: when to call MD, daily weights being done?, etc.

23. Questions and Discussion Ways to Get Involved in the Discussion Follow operator’s instructions to ask a question Type your question in chat Use the HRET discussion board to ask questions or share your experiences

24. HCAHPS Curriculum 2012-13All Web conferences are scheduled for 12-1pm Eastern • December 7, 2012: Fundamentals of HCAHPS • December 18/19, 2012: Using HCAHPS Data Effectively • January 16, 2013: Nurse Communication • February 13, 2013: Responsiveness • March 13, 2013: Medication Communication • April 24, 2013: Discharge Information • May 15, 2013: Physician Communication and Engagement • June 5, 2013: Pain Management • July 17, 2013: Clean • August 14, 2013: Quiet