Medication Reconciliation: Avoiding the "Med Wreck"



is it a conference recently where they used the term med rec instead of med rec and I thought oh my gosh of course that's exactly what we're doing we're med wrecking things and so how do we get beyond that how do we get to the magic and so basically what we're gonna be talking about today is what the heck is it how do we do it and then how do we all get engaged in the process because I think it can be very scary you know I went through six years of pharmacy school no more than that because I did my BS and then I did my doctorate and we've got a lot of people who are either coming in very new to this if you are one of the health coaches maybe is an RN even as physicians the amount of time you spend actually learning about drugs is quite short but the amount of time you spend interacting with those medications when you're out with patients is huge and so how do I as a pharmacist help get you to a point where you can interact with med lists within the scope of your practice and so that's what we're gonna focus on I'm not trying to get you to be a pharmacist but I want to get you to the point where you're comfortable making interactions with med lists that are appropriate to your skill sets so that's me we did an introduction already my area specialty or my area focus my soapbox that I like to get up on is pharmacists integration into the primary care setting I think that we have in our country in in the world a huge oversight in where pharmacists actually fall into the healthcare setting so right now pharmacists in the hospital are right there with the providers they review medications immediately when they're ordered before they ever get to the patient in the outpatient setting you've got the pharmacist so far removed from the rest of the care team and trying to make clinical decisions without actually having any of the information that they need to be part of that team and yet you're still having a system rely on them so my focus is actually getting pharmacists more and more integrated and we do that through a residency program we train residents on you know how to become integrated in the care team then I also have a second year residency where they learn how to become leaders and go out and propagate this model in other settings so if you ever want to hear more about that my soapbox is right over there I'm happy to bring it out but that's not today so the question is why am I even here talking to you guys about this everybody is doing my drive everywhere in the health system but the truth is you are actually the best people to possibly be doing that Rach there are so many places where the system is designed to fail you don't have all of the information you don't have the patients drugs that are right there with you but when you actually go out into the home and you have access to the patient you have the access to the medical records you've got access to providers and access to the medications you are set up for success you are essentially the only people in the health system who are set up for success so you go on-site and you actually have conversations about what is it that you're doing what are you taking and you can actually see all of those things that we're not able to see when we're in the office or when we're in the hospital we've got you know a list in the computer system is that accurate and the patient comes in and tells you what they're taking have they remembered everything have they selectively left things off that they don't necessarily want you to know about for one reason or another and so you know I think the CCT has the advantage of perception versus reality so clearly this is what every medication cabinet looks like when a patient comes into the office I'm perfect I'm taking everything just the way you have prescribed it and so I know when I go for my appointments and I talk to my MA she says you know any changes since last time and I say no and then I think oh my gosh it's been a year since I've been here I didn't even know what you had on my list and I take one or two medications so maybe there has been either husband has it been a month two months three months I don't know so then everyone said well a prod and be like well what what do you have on there right but our patients aren't necessarily trained to ask that question I'm a pharmacist so then I'll find out oh gosh no I'm not taking that anymore that was that that's all done now but our patients don't necessarily know to do that and so when you go out into the homes you're gonna see something more like this and this is the medication reality and this is terrifying but but you know I know what my house looks like and I know I can out of confess I have my stepson was on a medication it's still in the drawer they stopped it why am I not thrown I'm a pharmacist I know better haven't done it yet it's still there so I know that this is reality because I should be able to show you this one in my house they can't and patients are the same and so when you get out there and you get into the homes it's not just the process that we have in the office so it's not just you coming to my house and saying hey Felicity you know you still on the same meds okay crate that I'll just click this box and we're gonna move on because now you can say ok Felicity let's let's get them out what have you got in the store and and what is this medication doing here and it's clearly not on your list anymore so there's so many advantages that make you actually the group of people who can do true medication reconciliation and so the second part what the heck is medication reconciliation and I think that as I prepared for this as a pharmacist intuitively I know what it is because that's what they trained us on but I don't really know what it is because in the context where the definition came about it's actually in the hospital setting and so most of the Med rec definitions are not based on what we're doing ourselves and so if you go and you look it up it'll start with a list of medications that the patient is taking at home and a list of medications that you're planning on prescribing in the hospital setting that's not quite what we're doing we're just trying to figure out what is the patient taking now and then how do we work from that and so there's a couple definitions that I felt were more in line with what we're doing on the outpatient side but I still think that not necessarily grasping the entire complexity so I like the one from the Joint Commission it's the process of comparing the orders that the patient has so that would be your Med history that you have in your chart and then comparing that to what they've been taking I feel like that's the most accurate definition that I've seen and then reconciling that so getting those two lists together and reconciling finding out what the differences are so that you can avoid the medication errors so you can avoid the emissions and duplications the drug interactions when you add that level there's a whole nother level of complexity that you've just put on so you can do direct list comparisons but there's gonna be a point where you feel like you know addressing the dosing errors or addressing the drug interactions is beyond the scope of what you're going to be comfortable doing or be equipped to do in this in the CCT home setting and so we're gonna go through that in a little bit but regrouping so there's a certain amount you can do when you're out in the home and then knowing you have to come back and pull the team back in to actually be able to complete the medication reconciliation process for what its intended the CMS definition again is good but it's not quite as good a fit for what we're doing I said I just wanted to do a little bit of a contrast between the two this one is more about the list whereas the Joint Commission one it's really getting into the heart of what why we're doing the Med rec it's a this child right here this is how we all did feel every single time we have to do a metric oh gosh another one again you know it just captures the essence of it they made me put on the bunny suit and and now here Here I am and and I can't get out of this and then oh I've got to do it because it's the right thing for the patient but gosh I really really don't want to do this and I think that the biggest reason that we feel that way is because it is truly so hard to do a real metric first of all you know what your list look like in your EMR they can be pretty rough sometimes and then getting from the patient as well what they're taking and what they're doing is also a big challenge and so I I will start with there's no such thing as a perfect med list there never will be but what you're shooting for is the best possible list you can get by being in the home and having access to the medications the patients are on you can get a whole lot closer to that but I would never ever expect perfection and the further away you move from that direct access with the patient to the actual medications they're taking the further and further you get from being able to have a good med list and so what is medication reconciliation it's a process it's not it's it's not just one thing it is the whole process of what are they taking should they be taking lining those two up and then we get into the clinical decision-making so or have they stopped things that they should be on just because they stopped it doesn't mean we want to take it off the Med list maybe we need to address it or are there things that are on the list that shouldn't be there and that's appropriate so you're going to make some clinical decisions and then you're going to communicate that with the patient and in the home setting it's probably not going to be a new list you're giving the patient at that point in time if you're going to be making changes to the Med list there's probably other engagement that's going to happen beyond what they're already doing but definitely communicating that with the caregiver group to make sure that if there are changes that have to be made beyond sort of the the most obvious ones that that's happening and so caregivers extends beyond just the primary care provider you want to think about mental health professionals you want to think about any specialists always plugs for pharmacists because if you don't communicate with the patient's pharmacy that's still active on their medication profile and when we get the call bling-bling hello I'd like to you to refill all my medications well which ones would you want all of them everyone that's due ok that's what we're gonna do patients going to come back in pick up those medications and we're gonna start the cycle again so really really important to be communicating and so it really is more than just a conversation and so you're yours I love I love the person sitting down that's what you're what you're doing you're sitting down and you're going through each of the medications with the patient and you know you're gonna see do they know why they're on this are they actually taking this what do they believe they're using it for how are they taking it things like inhalers it's really important you know are they using a proper inhaler technique are they swallowing their Spy Reva capsules you know we're not gonna see a positive effect if they're taking things the wrong way and so it's having a real deep deep dive into what they're doing with their medications and so it's getting underneath the bed if that's where the meds are or looking in the cupboards and you know and and not being intrusive to the patient but engaging them in the process so that we can get an accurate Med list and so that we can really make sure that they're on therapies that are safe effective for them and so I made this because as I was thinking about you know how do I get a large diverse group of people to the point where they're ready to interact with the medallist I thought I don't even know how to do this I went to school for infinity years and and it's still a challenge and I see how I work with residents for a year or two years how in the 15 minutes that I was given which is almost stuff do I get you guys to the point where you can actually feel comfortable interacting within that list and so I thought okay let's take it to a point where no matter who you are there's gonna be a level of interaction that you can have and so I've broken it down and this is this is all me this isn't something that's out there this is just my way of trying to communicate to you how you can go about doing this and so it's broken down into the basic so it's things that with your baseline knowledge no water no matter what your experience is that you can do immediately within seconds and it's it's your baseline knowledge and as I wrote this I said oh yeah CF patients that they're taking ibuprofen it's not prescribed that's a no-brainer and then I thought oh wait no that's my baseline knowledge because I'm a pharmacist so that's not the baseline knowledge for me but it's a good example of how I fall on this so I would immediately have the conversation about this can exacerbate your symptoms of heart failure this isn't something that would be a good option let's talk about other medications that are over-the-counter know if it's somebody who's coming in and brand new to healthcare and there's a medication let's say it's an antibiotic and it's been discontinued on the Med list the patient is long past when the course was finished but they still have some laying around well you know that's an obvious with a very low baseline level of knowledge about medications you know that they don't have an active infection and you know that it's three months past when they were supposed to take it they never finished it that's not something that they need to be taking right now so that's a level of interaction you can have within that list or you're looking at it this is what we've printed out from our EMR and I see that this was a short course of antibiotics and I know that I just need to remove this from the Med list so there's the very basic then you get to simple things that are a few minutes or their quick resolution and so you have accessible information and so again this is Felicity with her pharmacists perspective of what do I consider to be simple and so if I have a patient and they have a high cardiac risk and they're on to statins there's there's no reason for someone to be on a duplicate therapy like that and I would look at you know what's their risk they've had at MI and I'm concerned about them so we've got a low potency a high potency I'm gonna want them to be on the high potency statin so again that it's bringing in my level of baseline knowledge but it's something that it will take me a few minutes I'm gonna look at you know what are they on I'm gonna consider their risks and then I'm gonna make a decision from there you know and and so it may be a matter of you have the Med list you see that there's two statins and then you notice and in the records that you have that one was discontinued so now you know you can educate the patient all right you're gonna keep taking your lipitor but you're gonna stop taking your simvastatin so you've got the information there it took you you know you had to go access some information but you were able to see that when you get into the moderate level of complexity that's when you know if it's it's gonna require some research so it may not happen right there and then and depending on where your baseline level of knowledge is you may hit that a lot sooner so you may hit that with the ibuprofen if you're you know have a basic level of knowledge however you know if you've got somebody like Corey you're gonna hit that way out here you know and so it's all based on where you're falling but for me I would think that if someone's on multiple blood-pressure medications that's something I'm gonna want to look into you know if they're on two or three four or five then I'm you know I've got to research it what are they really supposed to be on are we really on the right medications and then you get into the complex situations and that's ours does it'll it's the delay you're probably going to require a higher level of expertise and so for me an example is somebody's on 20 meds they've also got her bowls over-the-counter products and they have bipolar and an autoimmune disorder and so that's when I you know I back up okay this is if I'm gonna make any changes at all that are not falling in those original categories this is where I really have to engage the team and so what I encourage you to do is that anytime you're interacting in the situation of medication reconciliation anytime you're working with a med list is to figure out where it's falling on your level of knowledge and so you don't want to practice beyond what your knowledge is because then you introduce risk to yourself and to your patient but when you can figure out where it is that you're falling then you can figure out okay do I just need to pull a little bit more information this is within the scope of what I feel comfortable with practice or is it somewhere where I need to go back and engage the whole team and there are gonna be a lot of situations where it's gonna fall into one of these so I've been given my five minute sign and I'm like Cory's they didn't have to flag me down but but I think about it this way so basic is like flipping a light switch okay everybody can flip a light switch and then when I think about simple and sleek lighting a candle it's not that hard I can do that all right modern it's starting a fire it depends on the day I may be seeking assistance with that and then complexes rubbing sticks and I'm not even gonna try that I'm gonna engage an expert in making that happen so that's just sort of analogy for how to think about where you're falling on the level of the spectrum but the key is just identifying what is the complexity and utilizing the appropriate resources for managing that and so shameless plug for pharmacist because that's who I am and that's what I do getting to the magic having a pharmacist on your team allows for CCT to have additional medication expert resources and so integrating the pharmacist into it gives you that expertise for helping manage those moderate to complex situations and so then also plug for medication therapy management because that's the next step beyond medication reconciliation and that's the medical care provided by a pharmacist whose aim is to optimize drug therapy and improve therapeutic outcomes so it's taking what you've done in the mad wreck to the next step and we actually on occasion send our pharmacists out to the homes with the CCT teams we we try and get engaged as much as possible when we have complex patients we have a referral process where we can work them out and so in my last two seconds because time travels so quickly on your table there's handouts and the handout is basically a pharmacist met with a patient and they did a medication reconciliation and so I'm gonna ask quick questions if you look down the list and you have no time to review it at all so it's a really clinically accurate situation what changes that you would make within where you feel comfortable and don't look at page two that's the surprise for after so on page one are there things that you would feel comfortable with interacting with the Med list and I'm hearing rumblings and I'll pick on Carrie Lim because I brought a plant Carolyn is one of my residents so Carolyn gave me something really easy that you would feel totally fine with adjusting the Med list for okay and I'll give you a go to go down to the bottom corner right so that's something that on first glance it's it's a really easy interaction you know that the patient's not taking them anymore so you're empowered to actually edit the Med list and take those off you know you're gonna want to communicate to the members of the care team what's going on because if they come in and they they're expecting the patient has led cramps and those meds are gone they may you know you may get it restarted but communicating that the patient hasn't had any issues with leg cramps and now this is what's they're no longer taking it we don't need that on there the patient doesn't need to be continuing to get that refilled because they're just not using it so it's a it's a very basic level the surprise being when you turn to the second page and to the third the the pharmacist has actually gone through and done quite a comprehensive med review and it gives you a lot of details not only about the things that the patient isn't taking currently but the things that the patients are you know maybe questionable therapy so looking at the fact that they have a proton pump inhibitor and an h2 receptor antagonist both to treat their GERD there's not a lot of evidence for doing that so perhaps streamlining their therapy just trying one of those if that's sufficient then we're good if not then we can explore other options and so to wrap up because I know I'm pretty much done you know when I started out as a pharmacist it was very very intimidating I remember being in with the providers they were cardiologists and they hold hearts in their hands so clearly they know everything about everything and I was a new grad and some of them had practice for longer than I'd they'll live and so getting to the point where I was comfortable going to them and and suggesting that we make all of these changes was a challenge but I always reminded myself you know this is my job I'm paid to be here to do this to care for these patients so I have to step up and do it but the interesting thing that I learned over time was that the providers also have that same fear with interacting with the Med list so I would get the hospital list who didn't want to touch anything on the Med list because he wasn't the person writing those original prescriptions and so he wasn't quite sure what was going on there and then you get the primary care provider but the patient just came out of the hospital so clearly the hospitalist knows what they're doing so they don't want to touch the new meds because if they're on a PPI from the hospital they must have needed it it couldn't be that they were in the ICU and they were using that for asset suppression you know there's a lot of things that go along with a stay that are just meant to stay within that hospital visit you don't need to send everybody home on two tabs of Senna because they had a pain med in the hospital and so knowing that everybody is is nervous about interacting with the Med list it's really my intention today to empower you to figure out where it is you fall on that scale for each interaction that you're gonna have within that list and and to either address it as is appropriate or to make sure that you engage the team in the situation to manage the Med list and shameless plug for pulling pharmacist in because when you have a medication expert on the team it makes everybody's job easier and using the right tool for the job is key and then that's it questions and I don't know if we have any time but oh my oh no I just wanted to point out that Felicity makes a really good case for integrating pharmacy consulting into all of the community care teams and with the memorandum and Miranda of agreement that are going out this year for the two-year extension we've made some revisions and the requirements for Community Care teams and it is now a requirement that each community here team have some element of pharmacy consulting available so this should be viewed by all of you as a resource so when you have a question about medications like Felicity was just talking about that there is somebody that you can go to to ask that question and likewise there's somebody that you can connect with the providers and the practices that you're working with if there's a question about the medication management for the patient so please join me in thanking Felicity for being here with us today

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