Medication
Reconciliation for
the Elderly
Population
H. Edward Davidson, PharmD, MPH
Asst. Professor, Clinical Internal Medicine
Eastern Virginia Medical School
Partner, Insight Therapeutics, LLC
Learning Objectives
 To define medication reconciliation and its role in patientcentered care
 To illustrate the types of medication related problems
associated with transitions of care
 To describe a method for health care providers and
institutions to evaluate their transition of care processes
“Medications are probably
the single most important
health care technology in
preventing illness, disability,
and death in the geriatric
population.”
Avorn J. Medication use and the elderly: current status and
opportunities. Health Affairs 1995.
Clinical Practice Guidelines, the
Elderly, and Multiple Comorbid
Conditions
 Hypothetical 79-yr-old woman with COPD,
Type 2 DM, osteoarthritis, hypertension, and
osteoporosis
 If followed published CPGs would
 Be prescribed 12 routine medications
 Cost of $406/month
 Implications in pay-for-performance initiatives
 Increase risk of medication related problems
 Different settings, different goals
 Potential for diminished quality of care
Boyd CM et al. JAMA 2005;295:716-24.
Adverse Drug Events and the Elderly
Individuals > 65 yrs more likely than younger to suffer an
ADE; RR 2.4 (95% CI 1.8-3.0)
Budnitz DS et al. JAMA 2006:296:1858-66
Budnitz et al. New Engl J Med 2011;365:2002-12.
Independent Risk Factors for
Having a Preventable ADE in NFs
Risk Factor
Odds Ratio
Male
0.55
No. regularly scheduled meds
0-4
5-6
7-8
>=9
New resident+
+within
95% CI
0.30 - 0.99
1.0
1.7
3.2
2.9
Referent
0.83 - 3.5
1.4 - 6.9
1.3 - 6.8
2.9
1.5 -5.7
60 days of admission
Field TS, Gurwitz JH et al. Arch Intern Med 2001;161:1629-34.
What is Medication
Reconciliation?
 Joint Commission:
 The process of comparing a patient's medication orders to all
of the medications that the patient has been taking
 Reconciliation is done to avoid medication errors such as
omissions, duplications, interactions, and the need to continue
medications
 Provides the patient/resident (or family) with written
information on the medications they should take
 Explains the importance of managing medication information
when he/she leaves the organization’s care
Evolution of Medication
Reconciliation
NPSG.08.01.01: Accurately and completely
reconcile medications across continuum of care
Implemented 1/2006
NPSG.03.06.01: Maintain and communicate
accurate patient medication information
Implemented 7/2011
Care Transitions After Acute Care
Hospital
11%
16%
Nursing
Facility
64%
10%
74%
Hospital
or TCU
13%
77%
Home
TCU = Transitional Care Unit
Coleman EA et al. Health Svcs Research 2004;37:1423-40.
Hospital Admission
On hospital admission, more than 50% of
patients have at least one medication
discrepancy*
 Approximately 40% of those have potential to
cause harm
* Discrepancy defined as error between admission
medication orders and patient interview of medication
history.
Cornish PL et al. Arch Intern Med 2005;165:424-9.
Hospital Discharge
On discharge from the hospital, 30% of
patients have at least one medication
discrepancy* with the potential to cause
possible or probable harm
*Most common
discrepancy is omission of
pre-admit medication.
Kwan Y et al. Arch Intern Med 2007;167:1034-40.
Adverse Events in Nursing
Home Residents Transferred to
the Hospital
 122 nursing home to hospital transfers
 98% returned to the nursing home
 In 86% of transfers, at least one medication
order was altered (mean 1.4)
 65% - discontinued
 19% - dose changes
 10% - substitutions
 20% of changes resulted in an adverse event
Boockvar KS, Fishman E, Kyriacou CK et al. Arch Intern Med 2004;164:545-50.
Patient-Level
Contributing Factors
Non-intentional non-adherence
34%
Money/financial barriers
6%
Intentional non-adherence
5%
Didn’t fill prescription
5%
Other
1%
Subtotal
Coleman EA, Smith JD, Raha D, Min SJ. Arch Intern Med. 2005;165:1842-7.
51%
System-Level
Contributing Factors
D/C instructions incomplete/illegible
16%
Conflicting info from different sources
15%
Duplicative prescribing
Incorrect label
Other
Subtotal
8%
4%
7%
49%
Coleman EA, Smith JD, Raha D, Min SJ. Arch Intern Med. 2005;165:1842-7.
Best Practices: Medication
Reconciliation
Pharmacist involvement
 Inpatient setting on intake and discharge
 Post-discharge assessment/follow-up
 In-home review
Prioritize efforts
 High-risk patients (number of medications,
disease conditions (e.g., COPD, MI, heart failure)
 High-risk medications; opioids, insulin,
anticoagulants/antiplatelets, digoxin, oral
hypoglycemic agents
Medication List Toolkit
www.patientsafety.org/page/109587/
Why Evaluation?
Evaluation is the
conscious
reflection on
what we do
Improvement
Opportunities
Evaluation
Performance
as expected
over time
Did process
improve the
outcome?
Evaluation Research
 More rigorous than basic QI methods
 Involves developing an evaluable model
 A collective effort of all stakeholders
 Use of a measurement chart to identify variables
 Usually involves assessing baseline performance and
comparing to a post-intervention period (quasi-experimental
research designs)
Evaluation Scenario
Nursing
Home
 Rationale:
 Vulnerable elders
 OIG scrutiny (Medicare costs)
 Significant problems documented
Hospital/ED
Environmental Scan For
Measures
Joint Commission
National Quality Forum
Institute for Healthcare Information
ACOVE
CMS
AHRQ
Identify Process Nodes
Case study: In a nursing home to hospital bi-directional transfer, you
may consider that there are six exchanges
Exchange 1:
Preparation in nursing home to transfer patient to
hospital (nursing home handover)
Exchange 2:
EMS/Ambulance transport
Exchange 3:
Hospital receipt of patient
Exchange 4:
Preparation in hospital to transfer patient back to
nursing home (hospital handover)
Exchange 5:
EMS/Ambulance transport
Exchange 6:
Nursing home receipt of patient
Determine Evaluation Questions
Q1
Q2
Q3
• Is the appropriate information being
communicated to the ED/hospital by nursing
home staff?
• Is there documentation in the nursing home
medical record of communication with the
primary care physician about the ED/hospital
transfer?
• Is there documentation in the nursing home
medical record of communication with
family/caregiver about transfer of the
resident?
Develop Evaluation Matrix
Collect Data
Assess Current
Performance
% of charts with Yes response
Baseline Evaluation
100%
80%
60%
40%
20%
0%
1
2
3
4
5
6
7
8
9
Question #
10
11 12
13
14 15
Trend Results Over Time
original intervention
modified intervention
% of Charts with Yes Response
Original intervention
Modified intervention
100%
minimum
allowed
80%
60%
Question 6
Question 8
Question 9
Question 15
40%
20%
0%
baseline
Jul-08
Aug-08
Sep-08
Time Point
Oct-08
Nov-08
Web-based Evaluation Tool
What Can We Do?
 Evaluate our own practice settings
 Seek guidance of others:
 Example - www.ntocc.org,
www.cfmc.org/integratingcare/toolkit.htm
 Assure patient has:
 An updated medication list at each encounter
 An understanding of treatment plan
 An understanding of their role in care
 Assure providers have:
 An understanding of patient and caregiver preferences
 Knowledge of practice environment – policies, IT, etc.
 Access to tools to assist in improving care transitions, and
hence, communication of an accurate medication list