Review of a pharmacist discharge medication reconciliation program

Review of a pharmacist discharge medication reconciliation program: characterization of medication discrepancies and prescriber follow up in patients with and without recent hospital admission Brittany Reynolds, Pharm. D Candidate, Trista Pfeiffenberger Pharm. D, Monique Alford, Pharm. D BACKGROUND OBJECTIVES • Community Care of North Carolina (CCNC) is a group of nurse case managers and pharmacists who work with primary care providers (PCPs) as part of patient centered medical homes. • Compare medication discrepancies identified and prescriber follow up received in patients admitted for the first time versus readmitted patients, both of whom receive discharge medication reconciliation services by a hospital based pharmacist. • Access. Care is a network of CCNC which covers 24 of North Carolina’s 100 counties. • One component of Access. Care’s Transitional Care program involves a pharmacist conducting reconciliation and clinical review of medications on eligible hospitalized patients both during the hospital stay and at the time of discharge. • Compare medication discrepancies by high risk status of the drug, discrepancy type, and urgency. • Contrast first time admissions against readmissions for discharge diagnosis, total number of medications, comorbid conditions, and other demographic variables. DATA COLLECTION FORM PATIENT DEMOGRAPHICS Patient Identifier: Age: Patient’s first admission within last 6 mos? �Yes �No Length of Stay: _______ days Aged, Blind, Disabled status? �Yes �No Dual eligible? �Yes �No Case Management Status: �Medium �Heavy �Deferred �Pending Primary Discharge Diagnosis From Current Admission: _____________ Co-morbid Conditions: � CKD � ID/Parasitic Dx � ADHD/ADD � COPD � Liver � Anxiety � CVD � Muscular/Skeletal � Asthma � Depression � Nervous System � Bipolar � Diabetes � Psychosis � Blood/Blood forming organs � Endocrine/Metabolic � PTSD � Cancer � Genital/Urinary � Respiratory � Cerebrovascular/CVA � GI � Schizophrenia � CHF � HTN/CVD � Skin Diseases � Chronic Pain Previous admissions in last 6 months: Date: __________________ Primary Discharge Diagnosis: ____________________________ Date: _________ Primary Discharge Diagnosis: ______________ Total Number of Medications: ____________ MEDICATION DISCREPANCIES High Risk Discrepancy Discrepant Drug Name Medication? Type (#) RISK FACTORS FOR READMISSION Early Hospital Discharge 2 Disease Progressio n Readmissio n Inadequate Follow Up 3 METHODS • Inclusion: Medicaid or dually eligible Medicare/Medicaid patients who received inpatient and discharge reconciliation services by an Access. Care pharmacist on or after July 1, 2010. • Methods: Data will be collected from the following sources Therapeutic Error 1, 2 Adverse Drug Effects 1, 2 • NC Medicaid claims information • CCNC case management information system • CCNC medication reconciliation documentation form • Documentation of communication between Access. Care pharmacist and hospitalist or PCP. • Analysis: Descriptive statistics will be used to compare the characteristics of patients with their first admission against patients with a previous admission in a six month period. Urgency Timing �Pre-hospital �Urgent �During/Post-hospital �Yes �No �Non-urgent �Unknown �Pre-hospital �Urgent �During/Post-hospital �Yes �Non-urgent �Unknown PROVIDER RECOMMENDATIONS AND FOLLOW UP Recommendation(s) sent to: �Hospitalist �PCP Follow-up from PCP: � Received; accepted ____/_____ recommendations �No follow-up documented Follow-up from Hospitalist: � Received; accepted ____/_____ recommendations �No follow-up documented DISCREPANCY IDENTIFICATION KEY 1. Discontinued medication per discharge 6. Absolute contraindication (Drug-drug, drug instructions, but still taking -dz, drug-food) 2. Not taking prescribed discharge 7. Interaction non-absolute (Drug-drug, drugmedications dz, drug-food) 3. Poor adherence to chronic medication (pre 8. Adverse event/side effect reported hospital visit) 9. Drug allergy 4. Medications dose/frequency/duration 10. Therapeutic duplication 5. Potential transcription error, combo drug, 11. Unconfirmed discontinuation misnaming 12. Unreported medications