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Coalition takes aim at med reconciliation
Teams work to integrate caregivers
One of the most complicated issues facing medical staff, patients, and their caregivers is medication reconciliation. The medicines a patient is taking when he or she enters a hospital should be reconciled with any new medication the patient is given or prescribed while in the hospital.
But often, experts say, this doesn't happen. Things may start off badly and end worse. A patient who is rushed to a hospital in an ambulance after a heart attack may bring along no medicine. A family member trying to account for another's medications may remember the name of a prescribed drug, but not the dosage or how often it's taken. Or someone may have a dim memory of a medication the patient no longer takes.
The problem can be compounded when a patient leaves one setting say, the intensive care unit of a hospital and moves to a sub-acute setting, where he or she may be prescribed even more medications. According to the Institute for Healthcare Improvement, 50% of all medication errors and 20% of "adverse drug events" in a hospital are caused by insufficient communication during transitions of care.
"When you overlap medication reconciliation with multiple medical conditions, that's when the reconciliation really becomes a nightmare," says Cheryl Phillips, MD, past president of the American Geriatrics Society and Chief Medical Officer at On Lok, Inc., in San Francisco.
In the hospital, when a patient is preparing for discharge, she may receive a complete list of medications, but may not be able to read. Or the patient's memory may be less than reliable and he may not recall whether he should take the medicine in the morning or the afternoon. Or the list itself may contain errors.
Teams of healthcare professionals from several New York hospitals, rehabilitation centers, nursing homes, and hospice organizations are participating in the Transitions in Care-Quality Improvement Collaborative (TC-QuIC), a part of the United Hospital Fund in New York City (http://www.uhfnyc.org/initiatives/family-caregiving). Team members know that most often, the responsibility for administering a patient's medications falls to a family member or close friend.
Ten years ago, Carol Levine, who directs the Families and Health Care Project (TC-QuIC is an initiative), and other healthcare professionals, convened focus groups to talk about some of the problems involved in transitions of care.
They wanted to hear from family members, the people who would be responsible for patients once they got home, and to learn how they might make the process smoother and safer for the patient.
"The overriding message was, 'I wasn't prepared,'" says Levine. "Today, if we repeated those focus groups, they would say the same thing louder and more vehemently."
A family caregiver in charge of another's medications may have to compare the hospital's name for a drug with what it might be called in his or her local pharmacy. The medicine may have a different name and a different price, it may be a brand name instead of a generic, or it may be something an insurance company is not going to pay for.
The teams in the collaborative first contact family members in the hospital to determine who will be responsible for overseeing the patient's care. Early on, they identify the family caregiver, assess that person's needs, and integrate them into the care plan.
"What works is to have one person who is going to be there," says Levine. "And to tell them often what's expected."
Later, they contact the family caregiver about medications. If the patient is moving to a nursing home for rehab, they contact the caregiver again about details relating to that transition and ask about medications.
"Going to the nursing home doesn't mean it's a long stay," Levine says. "We start planning with them for the day of discharge, finding out what preparations we need to make and what they need to have."
And they close the loop with the nursing home, making sure providers there have the necessary information about medications. When the patient goes home, a team member calls and checks in with both the caregiver and the patient, trying to learn if the medicine is causing any trouble.
"It's a continuous process to make sure everything is going right," Levine says. "The family member has to follow up as well, and to report if they see the patient acting strangely. Elderly people sometimes don't respond to medication the same way that younger people do."
Every family is different, with its own set of challenges, the TC-QuIC teams have found. The person designated as caregiver may have health problems of his or her own, or may not be willing to do what is required, such as administer an injection. Another family member may be willing to help, but be unable to do so because of a new baby, a physical disability, or a conflict at work.
"We talk with the caregiver and try to learn how we can get them the help that they need," Levine said. "We continue to check in with them to learn how we can help."
If a family member doesn't get the right instructions about medications and the patient has a reaction, he or she will be right back in an emergency room. So it's imperative that the caregiver understands how the medicine works and what he or she has to do.
The teams are keeping data about what works and what doesn't and are making changes as they go along, improving what they are doing as they are doing it. (There is information on how providers and family caregivers can work together at http://www.nextstepincare.org.) The collaborative teams found that the institutions that sent patients back and forth had never developed a systematic way to communicate. Now they have one and are making things better. Data are being collected from all members in the collaborative, which will end in June. Another will begin in the summer.
"In my own view, if any hospital can do a really top-notch job of medication reconciliation and medication training, they will see their readmissions go down," Levine said. "That's the real driver of these readmissions, and they are avoidable."