D.2 CM 11-135 MEDICATION RECONCILIATION PROCESS.pdf

D.2 CM 11-135 MEDICATION RECONCILIATION PROCESS

36C25922R0102

DEPARTMENT OF VETERAN’S AFFAIRS

Oklahoma City VA Health Care System

Center Memorandum 11-135 March 1, 2017

MEDICATION RECONCILIATION PROCESS

1. Summary: This center memorandum provides policy and procedures for medication reconciliation. This center memorandum will replace CM 11-135, dated December 4, 2012.

2. Purpose: To outline the policy and procedures to be followed in the process for accurately and completely reconciling patient medications across the continuum of care.

3. Policy: It is the policy of the OKC VA HCS that all eligible Veterans cared for within the health care system receive well-coordinated, safe, appropriate, and patient-centered medical care at all levels and transitions of the health care continuum as it pertains to the management of patient medication information.

4. Definitions:

a. Adverse Drug Event (ADE). An ADE is an injury from the use of a drug.

Under this definition, the term ADE includes harm caused by the drug (adverse drug reactions and overdoses) and harm from the use of the drug including dose reductions and discontinuation of drug therapy.

b. Adverse Event and Close Call Reporting. Adverse event and close call reporting is the reporting, review, or analysis of incidents involving patients that cause harm or have the potential for causing harm.

c. Adverse Drug Reaction (ADR). ADR is a response to a drug which is noxious and unintended and which occurs at doses normally used in people for prophylaxis, diagnosis, or therapy of disease or for the modification of physiologic function. ADRs can be mild, moderate, or serious in nature; likewise, they can be observed or historical.

d. Brown Bag Inventory. Brown Bag Inventory is a term coined by the action of a patient bringing his or her medication containers, often in a brown paper bag, to an episode of care whereby the clinician reviews the patient’s medication containers with the patient in an effort to compile an accurate list of the medications the patient is currently taking.

e. Local VA Medications. Local VA medications are medications ordered at the treating VA facility.

f. Medication Adherence. Medication adherence refers to the extent to which the use of a medication by a patient aligns with the stated medication use instructions.

g. Medication: Any prescription medications, sample medications, herbal remedies, vitamins, nutraceuticals, vaccines, or over-the-counter drugs;

diagnostic and contrast agents used on or administered to persons to diagnose, treat, or prevent disease or other abnormal conditions; radioactive medications, respiratory therapy treatments, parenteral nutrition, blood derivatives, and intravenous solutions (plain, with electrolytes and/or drugs); and any product designated by the Food and Drug Administration (FDA) as a drug. This definition of medication does not include enteral nutrition solutions (which are considered food products), oxygen, and other medical gases.

h. Medication Discrepancy: Medication discrepancies are unintentional differences found in the patient’s medication information when compared to the medication information available on the electronic health record. These discrepancies may be omissions, commissions, inappropriate duplications, changes, additions, contraindications and/or unclear information. These discrepancies may be generated from the patient or the health care system.

i. Medication Reconciliation: A process to ensure maintenance of accurate, safe, effective and, above all, patient centered medication information by:

(a) Obtaining medication information from the patient, caregiver, or family members.

(b) Comparing the information obtained from the patient, caregiver, or family member to the medication information available in the VA electronic medical record, including active medications, recently expired medications, medications given at other VA facilities (via remote data view), and non-VA medications, in order to identify and address discrepancies.

(c) Assembling and documenting the medication information in the VA electronic medical record.

(d) Communicating with and providing education to the patient, caregiver, or family members regarding updated medication information.

(e) Communicating relevant medication information to and between the appropriate members of the VA and non-VA health care team.

j. Non-VA Medications. Non-VA medications are non-VA provider prescribed medications filled at non-VA pharmacies, VA provider prescribed medication filled at non-VA pharmacies, herbals, over-the counter-medications, nutraceuticals, and alternative medications.

k. Non-VA Providers. Non-VA providers are community providers including physicians, advanced practice nurses, physician assistants, and other health care professionals who provide health care to Veteran patients outside of VA.

This includes services reimbursed by Fee-Basis, Department of Defense, Tri- Care, Medicare, private pay, and health insurance. Methods to communicate with non-VA providers include phone conversations, FAX, and correspondence by mail after compliance with patient privacy regulations.

l. Patient-focused Local Metrics. Patient-focused local metrics are metrics established at the local level. For example, discrepancy rates, the rates of unintentional differences found in the patients’ medication information when compared to the medication information available on the VA electronic medical record, may be used.

n. Patient Medication Information. Patient medication information is information on all the medications taken by the patient, how they are taking it, any problems they may be having and/or have had in the past. This may be obtained by brown bag inventory, verbal history, or patient, caregiver or family member-furnished medication list.

o. Remote VA Medications. Remote VA medications means medications ordered at any other VA facilities (viewed or imported via remote data view).

p. VA Medication Reconciliation External Review Process (EPRP).

EPRP is the process for chart review, including the minimum documentation requirements that provide evidence that Medication Reconciliation was performed at this episode of care.

q. VA Medication Reconciliation Performance Monitor. A VA Medication Reconciliation Performance Monitor includes two questions at the post discharge call process: “Did you receive an updated medication list when leaving this VA medical facility?” and “Do you know where to go to ask questions?”

r. VA Providers. VA providers are physicians, medical trainees, advanced practice nurses, physician assistants, and other health care professionals who provide primary care or specialty care within the limitations of their individual VA privileges or scopes of practice.

s. Veterans Receiving Dual Care. Veterans receiving dual care refers to Veterans who receive ongoing health care in both VA and non-VA health care settings.

5. Responsibility:

a. The Health Care System Director is responsible for:

(1) Assigning a Facility Medication Reconciliation POC who can receive information and help disseminate new knowledge of Medication

Reconciliation transferred from the VISN Medication Reconciliation POC as it is made available.

(2) Ensuring that local policies conform to the following critical quality and safety elements:

(a) Defines the roles, tasks, and steps of the Medication Reconciliation process;

(b) Defines that Medication Reconciliation is initiated at every episode or transition in level of care where medications will be administered, prescribed, modified, or may influence the care given;

(c) Outlines how care is coordinated with the appropriate members of the health care team, including non-VA providers, through effective communication mechanisms and in conformity with the most recent revision of VHA’s National Dual Care Policy.

(d) Defines the processes to be used when medications are outside of the scope of the health care team member performing components of Medication Reconciliation, such that the member has access to necessary resources and communication strategies to refer the patient to the appropriate provider in outpatient and inpatient settings;

(e) Outlines strategies that enable adherence to minimum documentation requirements in the VA electronic medical record including:

1. Patient, caregiver, or family member-provided medication information obtained at the episode of care is represented in the VA electronic medical record.

2. Comparison of this patient, caregiver, or family member-provided medication information to the medication information available in the VA electronic medical record. This documentation includes active medications, recently expired medications, non-VA medications, and medications given at other VA facilities (remote medications) highlighting the discrepancies identified and addressed.

3. Updated medication information at the end of the episode of care is represented in the VA electronic medical record (including changes relevant to the episode of care).

4. Ensure discharge information in the VA electronic medical record is consistent with discharge instructions provided to the patient, caregiver or family member at the end of the episode of care.

(f) Defines patient-focused local metrics to evaluate the quality and efficacy of the program.

(3) Ensuring processes exist which provide support to the patient, caregiver or family with being full and active partners in the Veteran’s medication information management.

(4) Ensuring that the multidisciplinary health care team is knowledgeable about and accepts stewardship of the process by complying with local policies.

(5) Ensuring that local policy conforms with guidance from accreditation organizations where applicable.

(6) Ensuring that the facility monitors compliance as appropriate. NOTE:

Resources for monitoring are VA Medication Reconciliation EPRP and the VA Medication Reconciliation Performance Monitor (IPEC).

b. The Facility COS is responsible for ensuring:

(1) VA providers are adequately trained and educated on the Medication Reconciliation process and understand its importance in the scope of quality patient care and patient safety.

(2) VA providers are knowledgeable about their lead role and responsibilities with respect to Medication Reconciliation.

(3) VA providers have been provided sufficient resources for inter-provider, inter-departmental, inter-facility, and inter-system communication which conforms to all relevant VA and VHA privacy policies and Federal law.

c. The Clinical and Administrative Service Chiefs will ensure that all employees are educated on and comply with this policy’s requirements.

d. The VA provider is responsible for:

(1) Completing Medication Reconciliation in accordance with local policy including medications prescribed by, or secured outside of, the VA system to diminish the potential safety risk for the dual care patient.

The provider will compare the medications a patient should be using (and is actually using) to the new medications that are ordered for the patient and resolve any discrepancies. A good faith effort will be made to collect accurate and complete medication information.

(2) Documenting a plan to address medication discrepancies that is commensurate with the severity of the discrepancy and the risk of patient harm. NOTE: Addressing a discrepancy does not always require managing a medication or changing the medication order.

(3) Educating patients identified as dual care users as per VHA's National Dual Care Policy.

(4) Documenting and reporting adverse events and close calls and reporting. All adverse drug events must be entered into the Computerized Patient Record System (CPRS) and the VA Adverse Drug Event Reporting System (ADERS) as defined by VHA policy regarding Adverse Drug Event Reporting and Monitoring. NOTE:

Employees becoming aware of adverse events or close calls report them to the medical center via VA Form 10-2633 Report of Special Incident Involving a Beneficiary or other locally approved channels.

Current examples of adverse events, which require review and reporting, are included in VHA Handbook 1050.01.

(5) Assisting the Veteran patient, caregiver, or family member to maintain, update, and take ownership of the patient's medication information.

Patients need to be encouraged to be active participants in the decision making of their treatment plan. As such, the patient, caregiver or family member should share with the patient’s health care team:

(a) The Veteran patient’s goals of care;

(b) Personal medication utilization;

(c) Problems which affect medication adherence, such as:

1. Allergies and/or ADRs,

2. Difficulties with access to health care,

3. Financial hardship,

4. Recommended medication treatment plan declined, or

5. Other health-system, condition, or therapy-related factors

(d) Non-VA medication and provider information;

(e) Any medication and provider information from other VAMC facilities; and

(f) The patient’s health care proxy, if there is one.

DI.The Patient Safety Committee, or designated subcommittee, is responsible for:

(1) Performing periodic Medication Reconciliation process review to monitor compliance with this policy;

(2) Reporting results on monitors to patient care areas; and

(3) Delivering feedback to the Chief of Staff and Service Chiefs.

1. Procedures:

Providers will retrieve and review the complete list of the patient’s medications and known adverse drug reactions and allergies (via CPRS) with the patient or surrogate upon patient arrival to a given care setting. Upon inpatient admission, Nursing will document all allergies in the Multidisciplinary Screening Inventory (MSI).

Any change in allergy should be documented in the CPRS allergy field by the care provider It is incumbent upon the care provider to verify the complete list of the patient’s active medications (including VA prescribed medications (local and remote), non-VA prescribed medications, over-the-counter medications, and pending medication orders where relevant) and document or resolve recognized discrepancies. The processes used to achieve these goals are in part dependent upon the setting of care. The following processes cover the situations typically encountered within the Oklahoma City VA Health Care System.

Written information provided to patients on the medications they should be taking will include the name of the medication, the dose, frequency, and purpose.

The importance of managing medication information will be explained to the patient when he or she is discharged from the hospital or at the end of an outpatient encounter.

If the patient is participating in dual care or going to a non-VA provider, the patient will be instructed to give the medication list to his or her non-VA physician. The patient will also be instructed to update the information when medications are discontinued, doses are changed, or new medications (including OTC products) are added; and to carry medication information at all times in the event of emergency situations.

a. Patient visits to a VA clinic. VA clinic team members will review and amend the active medication list (to include VA prescribed medications (local and remote), non-VA prescribed medications, over-the-counter medications,) at VA clinic visits based on review of CPRS medication information as well as patient input. Patient input can be collected either prior to or during the clinical appointment. The provider will reconcile the medication list. The patient will be given written information on the medications the patients should be taking at the end of the outpatient encounter. Note:

When the only additional medications prescribed are for a short duration, the medication information the hospital provides may include only those medications.

b. Patients undergoing VA ambulatory surgery or other outpatient procedure:

VA provider will review and amend the active medication list (to include VA prescribed medications (local and remote), non-VA prescribed medications, on the day of and prior to any scheduled surgery or procedure. This reconciliation is based on review of CPRS medication information as well as patient input. The provider will reconcile medications and the patient will be given written information on the medications the patients should be taking when he or she is discharged. Note: When the only additional medications prescribed are for a short duration, the medication information the hospital provides may include only those medications.

c. Patients admitted to an inpatient service: The provider is responsible for retrieving a list of the VA prescribed medications (local and remote), non-VA prescribed medications, and over-the-counter (OTC) medications. The provider should discuss these medications with the patient or a competent surrogate and document the verified list in the electronic record. Documentation of recently taken medications (to include active medications, recently expired and/or discontinued medications , medications given at other VA facilities, and non-VA medications, VA prescribed medications, over-the-counter medications and herbal supplements should also be included in the health record. Within 24 hours after admission, there should be evidence in the medical record that a member of the healthcare team has reviewed all above mentioned categories of medications with the patient/caregiver and/or a medication list should be available in

CPRS.

d. Patients transferred within the Oklahoma City VA HCS inpatient facility:

Each time a patient is transferred to a new setting, the last active medication list must be reviewed by the recipient provider. The receiving provider will refer to this list to reconcile medications when transfer orders are written. If a patient is transferred to a non-VA facility, a paper copy of all current medications ordered must accompany the patient’s records.

e. Patients discharged from the inpatient service: It is the responsibility of the provider to compare the inpatient medication list with the previous outpatient medication list. Both lists may be retrieved from CPRS. The provider must indicate an action (i.e. continue, discontinue, renew, change) for each medication in both lists. This may be accomplished using the electronic unified action profile. A final medication list for the next care setting must be documented in the chart and written information on the medications the patients should be taking when he or she is discharged from the hospital will be provided to the patient prior to departure. The ‘Discharge Instructions’ satisfies this requirement. This list should also be communicated to the primary care provider.

f. Patients referred to other VA facilities: CPRS ‘remote data view’ is available and can be used to generate an active medication list.

g. Patients referred to non-VA Providers or non-VA facilities: An active medication list will be sent with the patient or faxed.

h. OKC VA Healthcare System Emergency Department: It is incumbent on the emergency care provider or ancillary support personnel to retrieve a list of active medications from CPRS at the time of patient presentation. The accuracy of the medication list should be reviewed with the patient or a competent surrogate and discrepancies should be noted in the care documentation. Upon discharge from the Emergency Department, written information on the medications the patients should be taking when he or she is discharged will be provided to the patient. Note: When the only additional medications prescribed are for a short duration, the medication information the hospital provides may include only those medications.

2. References:

CM 11-88 Physicians’ Orders

VHA Directive 2011-012 Medication Reconciliation

VHA Directive 1164- Essential Medication Information Standards

The Joint Commission. Comprehensive Accreditation Manual for Hospitals NPSG.03.06.01

3. Follow-up Responsibility: Chief of Staff (11)

4. Renewal Date: March 1, 2021

Kristopher W. Digitally signed by Kristopher W. Vlosich 163038 DN: dc=gov, dc=va, o=internal, ou=people, 0.9.2342.19200300.100.1.1=kristopher.vlosich@ va.gov, cn=Kristopher W. Vlosich 163038 Date: 2017.03.01 12:30:39 -06'00'

Kristopher Wade Vlosich Health Care System Director

Vlosich 163038