Medication Reconciliation (Med Rec) & Medication Therapy Management (MTM) PDF

Medication Reconciliation (Med Rec) & Medication Therapy Management (MTM) MATT IE M. FOLLEN, PHARMD, MS 1 Objectives ▪Define what a medication reconciliation (med rec) is ▪Identify what resources to use to help co...

Medication Reconciliation (Med Rec) & Medication Therapy Management (MTM) MATT IE M. FOLLEN, PHARMD, MS 1 Objectives ▪Define what a medication reconciliation (med rec) is ▪Identify what resources to use to help conduct a med rec ▪Discuss potential errors that can occur with a med rec ▪Discuss the process of how to go about conducting a med rec ▪Discuss how one should address a medication discrepancy when completing a med rec 2 Objectives ▪Define what medication therapy management (MTM) is ▪Understand the difference between a med rec and MTM ▪Identify what resources to use to help conduct MTM ▪Discuss potential barriers that can occur while performing MTM ▪Discuss the process of how to go about conducting MTM 3 Medication Reconciliation (Med Rec) 4 Medication Reconciliation Definition ▪Also known as a “med rec” ▪A process involved with comparing multiple medication lists to each other in order to compile the best updated medication list for a patient ▪Also involves rectifying medication-related issues when drug-therapy problems or discrepancies are identified 5 Purpose of a Med Rec Serves to minimize medication errors such as: ▪ Therapeutic duplications ▪ Unintended omissions ▪ Incorrect use of medications ▪ Drug-drug Interactions ▪ Drug-disease contraindications The main parts of a “med rec” are to: 1. Compile/update patient’s medication list 2. Rectify and resolve discrepancies & drug-related problems 6 Governing Bodies Institute for Healthcare Improvement (IHI) ▪ Medication reconciliation remains the top targeted intervention to prevent adverse drug events ▪ Poor communication of medical information during the transition of care is responsible for as many as 50% of all medication errors that occur in the hospital and 20% of adverse drug events The Joint Commission ▪ Accurate and complete reconciliation of medications across the continuum of care is a National Patient Safety Goal since 2005 ▪ Recommends that medication histories be reviewed and compared to current regimens on admission, transfer, and discharge Agency for Healthcare Research and Quality ▪ Devised a medication reconciliation toolkit ▪ https://www.ahrq.gov/patient-safety/settings/hospital/match/index.html 7 Settings Where a Med Rec is Performed ▪Hospital oEmergency department oAdmission oDischarge ▪Primary care physician’s office ▪Specialist physician’s office ▪Nursing home ▪Community pharmacy 8 When Should a Med Rec Be Performed? ▪Any point the patient is transitioned from one place to another ▪This is considered “transitions of care” ▪Examples Include: oHospital admissions oHospital discharge oFollowing-up with primary care provider (PCP) AFTER being discharged oNew to specialty office oNew to an outpatient pharmacy oSwitching from one PCP to another 9  Who Should Perform a Med Rec? ▪Nurses, pharmacists, pharmacy students, pharmacy technicians, physicians, medical assistants can perform a med rec ▪Clinical Study (Tong, et al): o 832 patients received some form of a medication reconciliation at discharge o In the group that received a standard discharge summary – 265 patients out of 431 had at least 1 documented error (61.5%) o In the group that had a med rec completed by a pharmacist – 60 patients out of 401 had at least 1 document error (15%) “Pharmacists are medication experts and have insight about target questions to ask patients when they review their chart for the medical history.” Tong EY, Roman CP, Mitra B, et al. Reducing medication errors in hospital discharge summaries: a randomised controlled trial. Med J Aust. 2017;206(1):36-39. 10 What Documents Should Be Utilized When Performing a Medication Reconciliation? ▪Discharge hospital records ▪Hospital medication orders ▪Nursing home medication records ▪Fill/refill history from pharmacy → Can help determine adherence to medications ▪Personal medication lists from patients ▪Insurance company claims ▪Patient’s pill bottles ▪From patient’s own recall → Several issues can occur using this alone 11 Example of a Patient Reported List ▪Glipizide 10 mg daily ▪Metformin 600 mg twice daily ▪Blood pressure medicine 25 mg daily ▪Blue pill once daily ▪Dr. Ron's Organic & Wildcrafted Heart Tonic daily 12 Community Pharmacy Fill History ▪List typically only contains medications filled at that particular pharmacy or chain of pharmacies ▪May be most up-to-date for recent fills ▪May contain refills for medications patient is no longer taking oPharmacies rarely get stop orders ▪OTC medications typically are not on list ▪Newer systems may allow for entry of historical meds 13  Utilize the Medication Bottle ▪Have the patient bring in all of their medication bottles ▪From the label you can see: oMedication information (name, strength, directions, etc) oPrescriber oFill date ▪The fill date can help determine if a patient is non-adherent ▪If it was last filled several months ago → likely non-adherent ▪Can also count number of pills in the bottle oIf many are still remaining → likely non-adherent http: //www. anim alwe lfare approv ed. us /wp -conte nt/uploads/2011/09/pil l-bottl e-326.j pg 14 Hospital Admission Record ▪The patient’s home medications are documented in the electronic health record (EHR) ▪List is typically patient/caregiver reported oShould be verified with another list! oVerify with patient’s community pharmacy (fill history)! ▪The admitting physician reviews the home med list and decides to either continue or discontinue each home medication during hospital stay 15 Discharge Medication List ▪A medication list given after a patient is discharged from a facility (i.e. hospital, rehab, or nursing home) ▪Most discharge lists provide the following information: oNew Medications oStopped Medications oContinued Medications oChanged Medications ▪NOTE: This list may not include home medications that were not continued during the stay or were not reported initially in the hospital records 16 17 Probing for More Information ▪If you suspect a medication list is not accurate for any reason you should probe for more information o i.e. Incorrect doses on list, duplicate therapy, unusual frequencies, etc. ▪Assess how the patient is actually taking medications o This is important for PRN medications o Look for phrases such as: “I’m supposed to take it…” “The bottle says…” “My doctor says…” ▪Be sure to look for warning signs of non-adherence o e.g. Many pills remaining in bottles o e.g. Late to refill or has not refilled at all ▪Just because a list says the patient is to take a medication does not mean the patient is actually taking it! 18 Common Medication Reconciliation Errors ▪Incorrect Dosing ▪Incorrect Directions o Patient takes clozapine 200 mg qAM and 50 mg o Rifampin 300 mg – 1 tab PO BID qPM o Should really read: 2 tablets PO daily o Discharged with 200 mg tablets only ▪Drug Omissions ▪Wrong Drug o Forgetting to include OTCs, vitamins, o Hydroxyzine pamoate vs. hydroxyzine HCl supplements, and minerals o Metoprolol succinate vs. metoprolol tartrate ▪Incorrect Formulation o Depakote ER vs. DR o Suspension vs. solution 19 Why Do Errors Occur? ▪Medication reconciliation is a complex process ▪It involves diligent work, active communication between the provider and patient, and critical thinking when discrepancies occur ▪Several reasons why these errors may occur is due to: oLack of understanding with medications oForgetting to document medications oNot asking about OTC/vitamins/herbals oNot addressing any medication discrepancies noted oPoor communication between providers 20 Conducting a Medication Reconciliation 21 Helpful Pointers ▪Take your time!!! ▪Prioritize oIdentify which drug-related problems are urgent vs. which can wait ▪Choose one list as your primary list (compare this to all others) ▪Organize: oMake a list of all medication discrepancies you found oWrite down how you are going to resolve each discrepancy oDo not ignore any discrepancies you find – all should be addressed! 22 The Six D’s to a Medication Reconciliation 1. Drug Name 6. Doctor 2. Dosage (prescribing medication) Form 5. Date Last 3. Dose Filled 4. Directions 23 Drug Name (preferably generic Spell name correctly! name) Determine what the drug is indicated for Tablet, capsule, solution, suspension, or injection Dosage form Immediate release vs. extended release vs. delayed release In milligrams, grams, units, mg/dL, mg/ml Dose Example: metformin 1 g, sitagliptin 100 mg Directions (includes route of By mouth vs. topically vs. intravenously vs. subQ administration & frequency) Once daily vs. twice daily vs. every 4-6 hours How long ago was it last filled and for what day-supply? Date last filled Date helps to see if patient is still actually taking the drug Which doctor prescribed it? PCP or specialist? Doctor Who should you discuss information with? 24 Completing a Medication Reconciliation ▪Select one medication list as the “reference list” ▪All other medication lists are compared to reference list ▪Group all medications into different “classifications” based on your findings such as: 1. Medications the patient takes but are NOT on my reference list 2. Medications the patient is NOT taking at all 3. Medications with discrepancy found in directions, route, or frequency 25 Medication Discrepancy Assessment ▪Each medication discrepancy should have a mini assessment & plan ▪Consider writing a 3-bullet point note under each discrepancy: oFirst line may talk about the current issue oSecond line may provide an assessment that may discuss previous history, lab reports, or symptomatology oThird line should discuss your course of action or plan of how to fix the discrepancy 26 Example Vitamin D3 2000 units PO daily ▪ Issue: Patient states she's not taking this medication ▪ Assessment: Last vitamin D level was low at 7 ng/mL on 6/8/22 ▪ Plan: Recommend to PCP to draw new lab and if still low patient will restart vitamin D 27 Example of Medication Discrepancy List 28 Last Few Pointers ▪Med recs can get very overwhelming when many discrepancies are found ▪Just remember to take NOTES on each discrepancy ▪Prioritize the issue from most important to least important ▪Be sure to identify the prescribing doctor first to discuss the discrepancy issue 29 Take Home Points ▪Medication reconciliation is a complex process that requires time and patience ▪Multiple medication lists may be available – use one as your “reference list” ▪Refill histories from community pharmacies provide an idea if patient is really taking a medication or not ▪Utilizing the 6 D’s to a med rec will help ensure accurate medication lists 30 Medication Therapy Management (MTM) 31 Med Rec vs. MTM MEDICATION RECONCILIATION MEDICATION THERAPY MANAGEMENT ▪Occurs at points of transition ▪Identifies medication-related problems ▪May identify medication-related problems ▪Helps patients understand all of their medications especially at any transition of care ▪Goal – capture an accurate medication list for as well as at discharge when they are faced the patient with how and when to take their medications on their own 32 Medication Therapy Management (MTM) Service that is reimbursed through Medicare Part D with specifically defined elements: 1. Comprehensive medication review (CMR) 2. Personal medication list (PML) oA record of all the patient’s medications (including over-the-counter medications, herbals, and dietary supplements) 3. Medication action plan (MAP) oA patient-centered document that empowers the patient to take personal action and track their progress of self-management 4. Intervention and referral to other healthcare professionals as appropriate 5. Documentation and follow-up 33 Comprehensive Medication Review (CMR) ▪A systematic process to achieve the following goals: o Collect patient-specific information o Assess medication therapies to identify medication-related problems o Develop a prioritized list of medication-related problems o Create a plan to resolve them with the patient, caregiver, and prescriber ▪Involves an interactive person-to-person or telehealth medication review and consultation o Conducted in real time between the patient or other authorized individual ▪Designed to improve patients’ knowledge of their prescriptions, OTCs, herbal therapies, along with dietary supplements ▪Identifies and addresses problems or concerns that patients may have ▪Empowers patients to manage their medications and health conditions 34 Factors That Can Affect the Choices Made During a CMR ▪Patient ▪Payers ▪Family/caregiver ▪Prescriber ▪Individual conducting CMR ▪Employer expectations 35  Patient identified as needing a CMR Contact patient to offer Schedule services and setup time to complete the CMR appointment with patient Patient agrees to complete CMR at time of CMR offer Complete pre-CMR CMR - Conduct interview - Review collected information and create plan Care plan PML MAP - Complete - Create list of all - Provide education Physician documentation prescriptions and OTC - Provide patient action communication - Plan follow-up medications statements 36 Performing a Preliminary CMR ▪Gather a medication list ▪Determine disease states ▪Identify patients’ healthcare providers ▪Identify potential medication-related problems 37 Conducting the CMR ▪Time management and efficiency are key ▪Informed consent must be obtained ▪Document medication usage ▪Collect health-related details oAdherence oIndications and therapeutic goals oLifestyle oSafety oEffectiveness 38 After the CMR – Care Plan ▪Without documentation, there will not be a complete record of the patient interaction and rationalization for the decision-making processes ▪Thorough documentation allows for continuity of care and is usually required for reimbursement ▪Any identified medication-related issues during the CMR should be documented o Medication-related issues identified during the pre-CMR may be resolved or identified as requiring further action o Newly discovered medication-related issues may become evident ▪The remaining clinically relevant medication-related issues should be prioritized, and the MTM provider should determine which require immediate action ▪Once the issues have been prioritized and the method of intervention identified, it is time to document the plan of action and follow-up for each of these issues in the care plan 39 Personal Medication List (PML) ▪Should contain all prescription medications, OTCs, and medical supplies ▪The following information should be included for each item of the PML: o Medication name o Dose of medication o Indication o Prescriber name o Directions for use o Special instructions ▪Other information that may be included on the PML can include date of birth, phone number, emergency contact information, primary care physician and contact information, pharmacy name and contact information, and allergies 40 Medication Action Plan (MAP) ▪The patient’s guide regarding any potential medication-related problems, disease- related problems, or general counseling provided by the MTM provider during the CMR encounter ▪Should only include information and goals that are within the pharmacist’s scope of practice, not issues that require prescriber approval or guidance ▪The most important counseling points should be prioritized ▪Should include appropriate word choice, spelling, and grammar to ensure that the information is clear and useful for the patient ▪The information must be an appropriate reading level for the patient 41 Prescriber Communication ▪May take place in many formats (fax, email, letter, phone call) ▪MTM pharmacist should determine whether an issue is urgent (requires a phone call) or non- urgent (fax, email, letter) o Examples of urgent situations: Patient has excessive bleeding from warfarin Severe drug interaction o Examples of non-urgent situations: Patient is missing a particular medication for a particular disease state Potential cost-saving opportunity has been identified ▪Communication with physicians should be concise yet thorough o Provide the physician with specific recommendations 42 Follow-Up ▪Required at least quarterly for Medicare Part D patients ▪May include a phone call, personal interview, or a review of the patient’s current health record and prescription refill history ▪MTM pharmacist should review and reassess actions that were determined for pertinent medication-related issues during the CMR ▪New medication-related problems arising from newly added or discontinued medication may also be identified oMTM pharmacist should document these and take appropriate action 43 References Gleason KM, Brake H, Agramonte V, Perfetti C. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. (Prepared by the Island Peer Review Organization, Inc., under Contract No. HHSA2902009000 13C.) AHRQ Publication No. 11(12) -0059. Rockville, MD: Agency for Healthcare Research and Quality. December 2011. Hardin HC, Salo J. Hardin H.C., & Salo J Hardin, Heather C., and Jennifer Salo.Conducting the Comprehensive Medication Review. In: Whalen K, Hardin HC. Whalen K, & Hardin H.C.(Eds.),Eds. Karen Whalen, and Heather C. Hardin.eds. Medication Therapy Management: A Comprehensive Approach, 2e. McGraw Hill; 2018. Accessed August 30, 2021. https://accesspharmacy.mhmedical.com/content.aspx?bookid=2319&sectionid=180048105 The Joint Commission. Accreditation, Health Care, Certification | Joint Commission. https://www.jointcommission.org/. Accesse d August 12, 2021. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care. https://www.ahrq.gov/professionals/quality-patient-safety/patient-safety- resources/resources/match/index.html. Published August 1, 2012. Tong EY, Roman CP, Mitra B, et al. Reducing medication errors in hospital discharge summaries: a randomised controlled trial. Med J Aust. 2017;206(1):36-39. 44  Medication Reconciliation (Med Rec) & Medication Therapy Management (MTM) MATT IE M. FOLLEN, PHARMD, MS 45