Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against a physician’s admission, transfer, and/or discharge orders, with the goal of accurately providing medications to the patient.
Hudson Headwaters Health Network (HHHN), with innovation funding support from the AHI PPS (Performing Provider System), launched the Clinical Pharmacy Services and Education Program in July 2019 for high-risk patients transitioning from hospital to the home, and skilled nursing facilities to the home, the most vulnerable of all populations for ADEs. The goal of the program is to increase the quality of care and improve patient outcomes in this identified high-risk population.
The initiative is a pilot involving HHHN and Fort Hudson Health System. HCR Home Care and Glens Falls Hospital are also project partners and recently the group was approached by Warren County Public Health to get involved. According to Kate Shmulsky, PharmD, Director, Population Health Programs and Quality at HHHN, that development was gratifying in that it confirmed the program could be used as a model that could be expanded to include additional partners.
Prior to program launch, HHHN, in May 2019, hired Ryan Armstrong, PharmD, Clinical Pharmacist, to coordinate the program. Armstrong was charged with getting the program off the ground, first looking at workflow efficiency and effectiveness, and then providing in-service education to clinicians, nurses, home health care managers and others involved in patient care. That process took approximately six weeks and went smoothly according to Armstrong. “We conducted pre- and post-training testing and participant’s scores increased dramatically,” shared Armstrong.
Currently, Armstrong is communicating with Fort Hudson and Warren County home health programs to identify Hudson Headwaters patients who are admitted to Glens Falls Hospital scheduled for discharge with home health services. This allows him to proactively review a patient’s medications and identify any discrepancies between the hospital discharge medication list and the medication list maintained by the patient’s primary care provider. The home health nurse will call Armstrong after visiting the patient in the home and the two will collaborate to identify any issues between the medications the patient is taking at home and what has been prescribed upon discharge. Armstrong then communicates any medication changes, discrepancies found, and additional recommendations to the patient’s primary care provider for their review. “The goal is to try and catch potential medication errors that may happen during transitions of care. With new medications being added and current medications being changed or stopped, it is vital to make sure the patient is not only taking the correct medications but is also on the most appropriate medications. We feel that adding a pharmacist review to the process gives us an added security measure to help prevent medication errors from happening.”
Armstrong shared an anecdote to illustrate this point. “A patient was discharged from a hospital with numerous medication changes and upon reconciling them with the home health nurse it was discovered the patient received medication from the pharmacy in bubble packs. Bubble packs are a convenient solution to help patients take their medications at the appropriate times and increase adherence to complex medication regimens. A patient’s medication regimen is packaged in separate ‘packs’ or ‘bubbles’ that are grouped together based on the time of day the medication is to be taken and a few weeks of medication are packaged for the patient at a time,” explained Armstrong. “This particular patient had numerous medication changes which meant that if they were to continue taking the bubble packs at home, they would have been taking the wrong dose, as well as medications that were discontinued. To resolve this, extra coordination was needed between the PCP, home health nurse, and pharmacy to ensure the patient received the correct medications.”
“In addition to medication reconciliation, there’s a second, equally exciting piece of this project and that’s our upcoming implementation of a new medication decision support software,” shared Shmulsky. After conducting thorough research, HHHN contracted with Tabula Rasa HealthCare®, Inc. to license MedWise™ technology to identify patients at high risk for medication-related problems by an assigned medication risk score that is based on accumulative multi-drug interactions to help manage a patient’s medications. The platform can provide point-of-prescribing medication decision support tools to help improve outcomes so that if a risk is identified, providers and pharmacists can work together to make changes. The chance to use these tools for more targeted interventions is exciting,” said Shmulsky.
The program has been useful for patients and providers alike. In addition to medication reconciliation and medication therapy management reviews, HHHN providers have also been able to request pharmacy consults within their electronic medical records that are routed directly to the clinical pharmacists. Both Armstrong and Shmulsky agree that focusing on high-risk patients who are undergoing transitions of care has proved helpful for everyone, and they are optimistic about the future of the program.
“Hudson Headwaters works to provide the best care, and access to that care, for everyone in our communities,” said Jane Hooper, Community Relations Manager at HHHN. “Working to ensure that patients also receive the best possible care during transitions from one care setting to another is another way that we partner with other organizations to keep the patient’s well-being and safety at the center of each decision made along the way.”
The AHI PPS-funded portion of the program was initially scheduled to sunset at the end of 2019 but has been extended through March 2020. Beyond that, the organization has made a commitment to sustaining the Clinical Pharmacy program even after innovation funding runs out.