Special Report: Improving Medication Reconciliation
DP improved by better admission med history
Community card organizes patients' med list
When Winchester (VA) Medical Center worked on developing a best practice in medication reconciliation and patient discharge, the hospital focused on one point-of-care delivery: the medication list at intake.
"The challenges for us remained on the front end, and that is to get the best possible medication list from patients," says Cynthia Rawlinson, CPHQ, corporate director of quality at Winchester Medical Center, which is part of Valley Health System.
There are many labor-intensive ways to improve intake medication histories, but hospital leaders decided to think outside the box. The key was to get patients to do a better job of recalling and listing their own medications, they theorized.
So, the solution was to create a community card, called simply the Medication List.
"We passed out these cards in public places like grocery stores, physician offices, and so forth," Rawlinson says. "It's a trifold card that lets you list every medication you have, along with the dose, and how often it's taken."
The card lists known allergies and reactions on the back and includes an emergency contact number.
The strategy worked.
"A lot of people now bring in the card complete with current information," Rawlinson says. "We distributed over 20,000 of these cards."
Also, community physicians have become more proactive, often giving their patients an updated list of medications at each visit. Then patients will carry these lists with them when they are admitted to the hospital, she adds.
"People have become savvy enough to understand why it's important to carry that list with them at all times," she explains. "If you're at the ballpark and become sick and are sent to the emergency department (ED), then you have the card and don't have to try to tell the nurse every medication you're on."
Another area of vulnerability in medication reconciliation is the transition from the ED to the inpatient unit. Up to 70% of patients seen in the ED are admitted to the hospital's inpatient unit, Rawlinson says.
"We're starting a program of having pharmacy technicians come into an express admissions unit to do medication reconciliation," she says. "They compile a list of home medications, and if there are any questions about the type of medication or dose, they'll contact the pharmacy and resolve those issues."
If this pilot project works as well as expected, then the program will be expanded to other patients who are directly admitted to the hospital, she adds.
Another proactive step is to print out patients' daily list of medications, including their home medications and current drugs. Physicians mark which of these should be continued or discontinued, Rawlinson says.
At the point of discharge, this thorough medication reconciliation process continues.
"We print out a current refrigerator list of their medications, and we go over it carefully with the patient to make sure they understand which home medicine they are to discontinue and which new medication will take its place," Rawlinson says.
"The discharge process gives us a chance to say, 'We see you have insurance, so will you be able to pay the copays on these drugs?'" Rawlinson says. "And if they cannot afford the drugs, then we engage in a different dialogue with them."
The hospital's readmission rate raised the alarm and helped identify this issue.
"When we were analyzing our readmission rate several years back and began to ask ourselves why we were seeing so many chronic disease patients come back, what we found is it was either related to lifestyle choices or medications," Rawlinson says. "We found through our discharge readmission data that patients would either buy the medication once and then take it for a week or they'd take it every fourth day and cut the drugs in half."
So, patients weren't receiving any value from the drugs they were prescribed, and they'd have acute episodes with their chronic diseases.
The hospital began to address this problem by improving chronic disease management services and addressing the drug affordability issue.
Now, the medication reconciliation process also contains a very important case management component, in which the discharge planner asks patients about their ability to afford new medications.
For example, if a patient cannot afford the expensive drug that the physician believes would provide the optimal therapeutic value, then the discharge planner will ask the doctor if a cheaper substitute might work, she explains.
"Drugs offer no value if the person can't afford to buy them," she adds. "So, if the patient can't afford the copay on a drug, then the nurse will call the physician, talk about the problem, and see if the physician could pick a cheaper drug even one of the $4 medications you can get at Wal-Mart."
This was added to the discharge process, because it gives discharge planners a nonjudgmental way and immediate way to determine a patient's ability to purchase the medications, Rawlinson says.
"You don't have to wait until the follow-up with the doctor at 30, 60, and 90 days to find out that they're not taking their medications at all," she adds.
Also, patients might be reluctant to admit to a doctor that a drug's cost is a problem, but they will be honest with a discharge planner when asked if they will be able to afford the drugs or the copays, she notes.
"The nurse asks in such a kind, personal manner that the patient or patient's spouse will speak up and say this is a problem for us," Rawlinson says.
Source
Cynthia Rawlinson, CPHQ, Corporate Director of Quality, Winchester Medical Center, Valley Health System, 1840 Amherst St., Winchester, VA 22601. Telephone: (540) 536-8000. E-mail: [email protected].
When Winchester (VA) Medical Center worked on developing a best practice in medication reconciliation and patient discharge, the hospital focused on one point-of-care delivery: the medication list at intake.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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