D.11 MCM 11-27 - MEDICATION RECONCILIATION PER VASDHS - ATTACHED.docx

D. 11 MCM 11-27 - MEDICATION RECONCILIATION PER VASDHS

MEDICATION RECONCILIATION

1. PURPOSE: To establish policy and procedures regarding medication reconciliation.

2. POLICY: This memorandum outlines a standardized method for creating and communicating an accurate list of the patient’s medication for inpatient care and for outpatient care.

3. DEFINITIONS:

a. Brown Bag Inventory: a patient brings his/her medication containers, often in a brown paper bag, to the clinician to review the patient’s medications in an effort to compile an accurate list of the medications the patient is currently taking.

b. Local VA Medication: Local VA medications are medications ordered at the treating VA facility.

c. 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.

d. Medication Discrepancy: Medication discrepancies are 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, and/or additions. These discrepancies may be generated by the patient or the health care system.

e. Medication Reconciliation: Medication reconciliation is a process to ensure maintenance of accurate, safe, effective, and, above all, patient centered medication information by:

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

2) 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 Joint Legacy Viewer), and non-VA medications, in order to identify and address discrepancies.

3) Documenting the medication information in the VA electronic medical record.

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

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

D.11 MCM 11-27 - MEDICATION RECONCILIATION PER VASDHS - 36C26225R0004

VA SAN DIEGO HEALTHCARE SYSTEM MEMORANDUM 11-27

SAN DIEGO, CA September 2, 2020

f. 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 and alternative medications are also considered non-VA medications.

g. 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, Tricare, 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.

h. 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.

i. Patient Medication Information: Patient medication information is information on all the medications taken by the patient, how they are taking it, and 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.

j. Remote VA Medications: Remote VA medications mean medications ordered at any other VA facility (viewed or imported via remote data view).

k. VA Medication Reconciliation External Peer Review Process (EPRP): EPRP is the process for chart review, including the minimum documentation requirements that provide evidence that Medication Reconciliation was performed during an episode of care.

l. VA Medication Reconciliation Performance Monitoring: A VA Medication Reconciliation Performance Monitor includes two questions at the post- discharge call process: “Were you provided a copy of your updated medication list upon discharge from this facility?” and “Do you know where to call to get more information or if symptoms deteriorate?”

m. 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.

4. RESPONSIBILITIES:

a. The Chief of Staff or designees is/are responsible for ensuring that Veterans are provided optimal and safe patient care. The Chief of Staff or designees standardize and maintain the medication reconciliation processes throughout VA San Diego Healthcare System. This includes the following critical quality and safety elements:

1) Defines the roles, tasks, and steps of the Medication Reconciliation process.

2) 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.

3) 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.

4) Defines the processes to be used when medications are outside 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.

5) Ensures that the facility monitors compliance as appropriate by defining patient-focused and local metrics to evaluate the quality and efficacy of the program.

6) 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;

7) 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. 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).

b. Clinical Service Chiefs are responsible for compliance with this policy and for monitoring compliance as it pertains to their service. They are responsible for ensuring that: VA providers adhere to training and education requirements for Medication Reconciliation processes; and VA providers are knowledgeable about the importance of medication reconciliation in quality and patient safety and their lead role and responsibilities with respect to Medication Reconciliation.

c. Attending physicians in all settings are responsible for appropriate resident supervision in medication management, including the educating house staff, students, and residents on the correct medication reconciliation process and ensuring consistent documentation for reconciling medication across the continuum of care.

d. Providers with prescribing privileges (i.e. physicians, registered nurse practitioners, physician assistants, pharmacists) are responsible for completing Medication Reconciliation in accordance with this policy including medications prescribed by or secured outside of the VA system to diminish the potential safety risk for the dual-care patient. Prescribers are responsible for documenting a plan to address medication discrepancies that is commensurate with the severity of the discrepancy and the risk of patient harm. Prescribers are also responsible for reconciling when medications are altered and as outlined in this policy (see Attachments A - D). Physicians performing procedures (e.g., cardiac cath, interventional radiological procedures) are responsible for reconciling the medication list prior to any procedures in which medications will be administered or when current medications may affect the outcome of the procedure.

e. Pharmacists are responsible for consulting the provider as needed with medication management of the patient, including reconciling medication on inpatient admissions, transfers and discharges. Dispensing Pharmacists identify, clarify, and resolve any medication discrepancies or problems with the ordering provider. Pharmacy Technicians assist Pharmacists in collecting patient medicine information and printing patient medicine lists.

f. Nurses (LVN and RN) assist prescribing providers in collecting and recording information regarding patient medicine use (VA and non-VA prescriptions, OTC drugs, dietary supplements or herbal products).

g. Patients actively participate in decision making for their treatment plan and inform the health care provider and/or team of any changes in their medicine regimen. The My HealtheVet internet website provides patients with access to their medicine list: https://www.myhealth.va.gov/index.html.In addition, the patient should share with the health care team: (1) the Veteran patient’s goals of care; (2) personal medication use; (3) problems which affect medication adherence, such as: allergies and/or ADRs, difficulties with access to health care, financial hardship, recommended medication treatment plan declined, other health- system, condition, or therapy-related factors; (4) non-VA medication and provider information; (5) any medication and provider information from other VAMC facilities; and (6) the patient’s health care proxy, if there is one.

5. PROCEDURES:

a. A complete list of the patient’s current medication, which includes prescriptions, over-the-counter drugs, vitamins, supplements and any product designated by the Federal Drug Administration (FDA) as a drug, is obtained with involvement of the patient, caregiver, or family members. A good faith effort will be made to obtain as complete a list as possible. Please refer to Attachment A which outlines the procedures in different settings and the key steps required for creating and communicating an accurate list of the patient’s medication for inpatient care at the time of admission, transfer, and discharge and for outpatient care.

b. The complete and current “list” of a patient’s medicine (name, dose, route, frequency, and, if appropriate, purpose) is synonymous with the list of Inpatient, Outpatient, and Non-VA medications as documented on the CPRS “Meds” tab, as well as medications ordered by providers at other VA sites (“Remote Meds”). The CPRS “Health Summary” for “Medication Reconciliation” accurately lists the patient’s outpatient Rx's, inpatient orders, remote and Non-VA medicine. Providers may use this list in their progress notes to document the medication reconciliation process.

c. With order entry of new or changed VA or Non-VA medications into the CPRS computer system, the CPRS “Health Summary” report “Medication Worksheet” and After Visit Summary automatically updates to include pending medication orders and can printed for patients at the end of the episode of care. This list will be available to the next provider of service, across the continuum of care, by maintaining it in the Computerized Patient Record System (CPRS) on the Meds List tab. If a patient is transferred to a non-Veteran Administration (VA) facility, a paper copy of all current medications should accompany the patient. Consult service will send a copy of the current medication list with every request for fee basis consult.

d. When the patient is being treated by a Non-VA provider, the patient is offered a Release of Information (ROI) form to allow the ROl department of Health Information Management Service (HIMS) to mail the reconciled medication list to the non-VA provider.

e. The reconciliation process includes a comparison of the medications on the list (including VA provided medicines and non-VA medicines) to the medications the patient reports that he/she is taking.

f. The medication information to be collected when medications are changed will be the name of drug, dose of drug, route to be given, the frequency, and purpose of the drug. The provider making adjustments to the medication(s) ordered for the patient will compare the medication information the patient is currently taking with the medications ordered for the patient to identify and resolve discrepancies. Discrepancies include omissions, duplications, contraindications, unclear information, and changes. For inpatient admissions, the computerized medication list is updated automatically with order entry and verification. The discharge medication list should include not only the medications that are prescribed at the time of discharge, but any other medications the patient should be taking. Patients will be provided an up-to-date list of their medications at the time of discharge.

g. The importance of managing medication information will be explained to the patient at the time when medications must be rewritten, to include at time of admission, transfer, discharge, at every outpatient primary care provider visit and at non-primary care visits when medications are changed. The patients and families involved in self-administration of the medications will be educated on the following: medication name, type, and reason for use, how to administer the medication, including process, time, frequency, route and dose.

6. REFERENCE:

a. VHA Directive 2011-12, Medication Reconciliation, March 9, 2011. VHA Directive 2011-012 “Medication Reconciliation”.

b. Joint Commission on Accreditation of Healthcare Organizations, current edition.

c. Joint Commission National Patient Safety Goal on Reconciling Medication Information (NPSG.03.06.01), available at: http://www.jointcommission.org/standards_information/npsgs.aspx

d. National Patient Safety Goal VHA Handbook 1050.01, VHA National Patient Safety Improvement Handbook, March 4, 2011

7. REVIEW DATE: September 2023.

8. FOLLOW-UP RESPONSIBILITY: Chief of Pharmacy (119)

9. RESCISSION: Memorandum 11-27 dated June 21, 2017.

10. DATE APPROVED BY MEC: October 7, 2020.

Attachments: A,B,C,D Distribution: SharePoint

All outpatient areas

All prescribers

2. Review the patient allergy history and past medication reactions prior to ordering new medications in CPRS or administering a new medication. Update drug allergies and adverse drug reactions in CPRS.

3. When medications are outside the scope of the health care team performing components of medication reconciliation, use resources and communication strategies to refer the patient to the appropriate provider.

4. Offer a medication list to the patient at the end of the appointment if the patient has not previously received an active medication list; OR (2) the medications have been changed since the last visit.

5. Review outpatient medication list with patient / caregiver (including herbals, dietary supplements, remote and non-VA medication). Counsel patients on new and changed medications which include regimen, potential side effects and purpose and provide medication information sheets as part of the medication teaching process.

6. Instruct the patient to dispose of medications he/she is no longer taking.

Outpatient Medication Reconciliation Process - Primary Care, Specialty and ED Quick Reference

MEMORANDUM 11-27

September 2, 2020

VA SAN DIEGO HEALTHCARE SYSTEM

Attachment A

Setting

When is it done?

What is required?

/ or within 12 hours of admission

1. Import the updated outpatient medication list into a CPRS progress note

2. Review outpatient medication list with patient / caregiver (including herbals, dietary supplements, remote and non-VA medication)

3. Document comparison of outpatient medication list with inpatient medication list in a CPRS progress note (including identifying and resolving discrepancies with prior outpatient prescriptions, such as, omissions, duplications, contraindications, and unclear information)

4. Update drug allergies and adverse drug reactions in CPRS

5. Respond promptly to communications from the inpatient pharmacist who identifies any unresolved discrepancies found when reviewing admission medication orders and as compared to outpatient medications

2. Communicate with the provider any unexplained discrepancies between the inpatient medication orders and the outpatient medication list.

3. If available on site, will follow up (if necessary) with attempts to complete the initial patient/caretaker review of medications.

VA SAN DIEGO HEALTHCARE SYSTEM

Attachment B:

MEMORANDUM 11-27

September 2, 2020 Inpatient Processes Medication Reconciliation – Inpatient/ASPIRE/SARRTP Process Quick Reference

2. If delayed transfer orders have been written, the provider will review the orders to ensure that any medication changes made between the time the delay orders were written and the transfer occurred are included in the transfer orders.

2. Discontinue any undesired medication(s) from the outpatient medication list in CPRS

3. Review expired outpatient medications and renew as necessary

4. Document the treatment plan in the discharge progress note in CPRS including the documentation of inpatient medications that will be continued upon discharge and new medications and/or dosage/schedule changes that will be added to the patient’s medication regimen

5. Order discharge medications, in sufficient quantities to last until the patient’s next outpatient visit.

6. Communicate the new medication regimen to the patient/caregiver. A discharge instructions sheet containing the medication regimen information will be provided to the patient/caregiver.

7. For those patients being sent to a skilled nursing facility paid by the VA, order discharge medications, including those where no changes occurred. Write these as new prescription orders, not as renewals, to be filled prior to the patient’s discharge

8. For those patients being transferred to another VA facility or a skilled nursing facility paid by Medicare, do not order discharge medications, but document the discharge medication list in the discharge note for continuum of care.

September 2, 2020

VA SAN DIEGO HEALTHCARE SYSTEM

Attachment B:

Inpatient Processes

2. Document any medication reconciliation discharge discrepancies in the patient Education/Pharmacy discharge note in CPRS with the discharge prescribing provider as an additional signer.

3. Provide discharge medication counseling to the patient/caregiver at the bedside or at the Pharmacy. Give the revised medication printout list to the patient during the counseling session.

VA SAN DIEGO HEALTHCARE SYSTEM MEMORANDUM 11-27

Attachment C: September 2, 2020 Inpatient Medication Reconciliation Template

Setting

When is it done?

What is required?

/ or within 12 hours of admission

1. Import the updated outpatient medication list into a CPRS progress note

2. Review outpatient medication list with patient / caregiver (including herbals dietary supplements, remote and non-VA medication)

3. Document comparison of existing medication list prior to admission with new inpatient medication list in a CPRS progress note (including identifying and resolving discrepancies with prior outpatient prescriptions, such as, omissions, duplications, contraindications, and unclear information)

4. Update drug allergies and adverse drug reactions in CPRS

5. Respond promptly to communications from the inpatient pharmacist who identifies any unresolved discrepancies found when reviewing admission medication orders and as compared to outpatient medications

2. Communicate with the provider any unexplained discrepancies between the inpatient medication orders and the outpatient medication list.

3. If available on site, will follow up (if necessary) with attempts to complete the initial patient/caretaker review of medications.

VA SAN DIEGO HEALTHCARE SYSTEM

Attachment D:

CLC Process Medication Reconciliation - CLC Process Quick Reference

2. If delayed transfer orders have been written, the provider will review the orders to ensure that any medication changes made between the time the delay orders were written and the transfer occurred are included in the transfer orders.

2. Discontinue any undesired medication(s) from the outpatient medication list in CPRS

3. Review expired outpatient medications and renew as necessary

4. Document the treatment plan in the discharge progress note in CPRS including the documentation of inpatient medications that will be continued upon discharge and new medications and/or dosage/schedule changes that will be added to the patient’s medication regimen

5. Order discharge medications, in sufficient quantities to last until the patient’s next outpatient visit.

6. Communicate the new medication regimen to the patient/caregiver. A discharge instructions sheet containing the medication regimen information will be provided to the patient/caregiver.

7. For those patients being sent to a skilled nursing facility paid by the VA, order discharge medications, including those where no changes occurred. Write these as new prescription orders, not as renewals, to be filled prior to the patient’s discharge

VA SAN DIEGO HEALTHCARE SYSTEM

Attachment D CLC Process

8. For those patients being transferred to another VA facility or a skilled nursing facility paid by Medicare, do not order discharge medications, but document the discharge medication list in the discharge note for continuum of care.

2. Document any medication reconciliation discharge discrepancies in the Patient Education/Pharmacy discharge note in CPRS with the discharge prescribing provider as an additional signer.

3. Provide discharge medication counseling to the patient/caregiver at the bedside or at the Pharmacy. Give the revised medication printout list to the patient during the counseling session.

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