Medication Use Crisis Sponsored by the VA Medication Reconciliation Initiative In conjunction with...

Medication Use CrisisSponsored by the VA Medication Reconciliation Initiative

In conjunction with VHA Program Offices, DoD and IHS

Key Transitions in Care Cincinnati PACT and Ann Arbor Clinical Demonstration Project:Barbara Robertson, ADDena Rattermann, MSN, RNChristine Cigolle, MD, MPHKristin Phillips, PharmD, CGP



PACT and Medication Reconciliation Cincinnati VAMC PACT Pilot Team

Barbara Robertson, ADDena Rattermann, MSN, RN

VETERANS ADMINISTRATION PATIENT CARE SERVICES

Teamlet Roles

PSA: Sends letter to patients asking that they bring an updated medication list to their appointment. They also provide patient with a copy of VA medication list to review for accuracy

LPN: performs med reconciliation with patients during intake and notes discrepancies for provider. Also performs med reconciliation during phone visits (including 2 days post discharge calls)

RN: performs med reconciliation with patients at RN visits and phone visits (including 2 days post discharge calls)

Provider: performs med reconciliation with all patients during phone, face to face and sigma visits

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Letter Sent to Patients:

Dear Patient, Your safety is our number one priority! In order to help us to prevent medication errors, we must know the complete list of medications you are

taking. We will cross-check the list against our records during your office visit.Before your next VA clinic visit, review the attached list of medications and follow these steps:Cross out any medications that you no longer take.Add any medications that you take which are not on the list. Include how much you take and when you take it (morning, evening, etc)Include medications prescribed by doctors outside the VA.Include over-the-counter medications such as aspirin or Tylenol. Also include vitamins, herbal remedies, and nutritional supplements.Correct the amount and/or times that you take any medications that are different from the amounts and/or times on the medication list.At your next VA clinic visit:Bring the attached list with you.Be sure to tell us all medication or IV contrast dye allergies that you have.It is often a good idea to bring all of your medications to the clinic visit in order for your health care provider to check them against the list.It is helpful to have a family member or caregiver with you during your visit. A second set of ears to listen to instructions and to ask medication

questions can be a big help.At the end of your clinic visit, your provider should update your medication list to reflect any new changes made as part of your treatment plan

as a result of your visit.Be sure that you are given a copy of your new updated list to take with you.Destroy all old medicine lists! Protect your identity and private health information.Take your medication list to all medical or dental appointments, whenever you have an outpatient procedure, or when you are being admitted

to the hospital.We welcome questions you may have about your medications or medication side effects. It is one of the best ways for you to be an active

partner in your health care.For questions about your medications that might arise after your visit, see the back of this handout for phone numbers.

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Advantages of PACT for Medication Reconciliation

• PSA reminds patients to prepare an updated medication list for visits which improves efficiency

• Improved accuracy of medication list due to repetition by multiple teamlet members

• RN and LPN help reconcile med lists over phone during routine follow-ups and hospital discharge follow-ups which helps us to prevent medication errors in between face to face visits

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Transitioning from Non VA to VA• DoD

– Close ties with the DoD Liaisons– Lots of communication during transitions

• New patients– Letters sent to veterans prior to appointment requesting Outside records, list of prescription and OTC Medications– Reminders calls prior to appointment

• Dual Care– Varies with each Primary Care site

• Relationships with community providers have been developed– Patient Education

• Clear expectations • Dual Care Policy• Responsibility to keep providers informed

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Patients Post Discharge

• From a VA Admission– Nurse Practitioner Discharge Liaison

• Ensures Follow-Up Appointment made• Medication Reconciliation• Team to Team Hand-offs

– Discharge Notification• Automated list of Discharges sent to Teamlet RN/LPN

– From a non VA Admission– Transfer Center Reorganization

• Enhancing Medication Reconciliation• Weekly Meeting work out process

– Pharmacy to Pharmacy

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Patients going in between PC and Specialty:New Frontiers

• Between Primary Care to Specialty Care– A challenge– Many joint projects with Specialty Care

• Specialty imbedded in Primary Care– Audiology, Cardiology, Ophthalmology

• Tele-Derm

– Education from Specialists for Primary Care– COPD Program

• Prevention• Multi-disciplinary• Entire Continuum of Care

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VETERANS ADMINISTRATION PATIENT CARE SERVICES 9

In between visits

• Case Management– Diabetic Nurse Practitioner– Training the RN Care Managers

• Telehealth– Expanding– CVT, Store and Forward, and CCHT

• Secure Messaging• Nurse Line



Ann Arbor Bridging the Gap: Care Management Targeting Veterans with Cognitive Impairment at Times

of TransitionChristine Cigolle, MD, MPHKristin Phillips, PharmD, CGP


Bridging the Gap: Care Management Targeting Veterans with Cognitive Impairment at Times of Transition

• Clinical Demonstration Project– Innovative Patient Centered Alternatives to Institutional Extended Care

• Transformation-21 (T-21) initiative– VA Ann Arbor Healthcare System (VAAAHS)

• Team members– Advanced practice nurse (0.5 FTE)– Clinical pharmacist (0.5 FTE)– Social Worker (0.5 FTE)– Geriatricians (0.25 FTE)

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Project Goals

• Goal 1: Provide seamless medical and social services to veterans with cognitive impairment in the transition between hospitalization and the veteran’s return to his medical home.

• Goal 2: Improve dementia care by providing diagnostic, medical management, and care management services to veterans with known or suspected cognitive impairment.

• Goal 3: Support caregivers/surrogates in their care of veterans with cognitive impairment.

• Goal 4: Facilitate the effectiveness of the patient-centered medical home for veterans with cognitive impairment.

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Project Goals Operationalized

• Coordinate with Patient Aligned Care Team (PACT).• Identify levels of patient functional impairment.• Identify levels of caregiver burden.• Identify medication discrepancies, problem medications, etc.• Assist caregivers with coping strategies.• Leverage available VA and outside support services.• Reduce medication errors, polypharmacy, etc.• Increase support staff in existing Geriatrics Clinic.

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Common Patient Transitions

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Subacute or Long-Stay Nursing Facility

Home, Assisted Living, Long-Stay Nursing Facility

Hospital

Emergency Department

Hospital

Home, Assisted Living

Home Assisted Living

Subacute Nursing Facility


Project Interventions

• Transitional Care Clinic– Embedded in current Geriatrics Clinic. – Flexible, rapidly accessible, and able to accommodate and

respond to wide breadth of veterans’ needs in the post-discharge period.

– Focus: Coordinate services for and support veteran in immediate post-discharge phase. Emphasis on supporting the caregiver.

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Project Interventions

• Expanded Ongoing Dementia Case Management– Services: Medication management. Accessing VA, Medicare, and

community resources (home health care, senior day care). Providing advice and recommendations by phone.

– Support the cognitively impaired veteran, his caregiver(s), and his primary health care team (patient-centered medical home).

– Sites beyond the VAAAHCS, with an emphasis on outreach to veterans and their caregivers living in rural areas.

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Target Population

• Include:– 60 years and older– Have (or suspected to have) cognitive impairment– Recent or anticipated transition (e.g., hospital discharge)

• Exclude: – Active substance abuse– Primary psychiatric diagnosis

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“Typical” Patient Seen in Clinic

• Mr. R. is a 90 year old male with cognitive impairment and multiple medical problems now having behavioral disturbances for which risperidone had been recently prescribed. He was living in a senior apartment when he presented to the ED with confusion. No sources of infection were found. The patient was referred to our clinic and enrolled in our project.

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Team Interventions for Mr. R

• Performed a complete geriatric and cognitive assessment.• Stopped risperidone and started donepezil.• Educated the family on non-pharmacological methods to deal with

behavioral disturbances and ways to improve interaction with the patient. • Identified multiple medication discrepancies and addressed them.• Addressed caregiver stress of his daughter, who was neglecting her own

health care.• Educated the family on VA and Medicare coverage.• Explored assisted living options and eventually provided services including

Meals on Wheels, home PT, home health aide, respite and HBPC.

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Pharmacist’s Role

• General– Medication adherence and knowledge assessment.– Patient/caregiver goal for medication therapy.– Psychotropic medication use.– Medications contributing to fall risk.– Review for Potentially Inappropriate Medications (PIMS)

• Specific to transitions– Instruct patients to bring medication bottles from all sources to each visit.– Obtain MAR from nursing facility prior to patient’s appointment (when applicable).– Ensure each patient leaves the appointment with an accurate medication list.– Follow-up call to patient’s home if discrepancy arises that cannot be resolved.– Call to patient’s home to reconcile medications if transition is known to have occurred.– Provide accurate, complete medication list to nursing facility during transition.

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Tools

• Patient-friendly medication list:– Easier to use and interpret than usual VA-issued medication list.

• Note templates:– Chart review on day prior to clinic appointment.

• Assess interim events/medication changes, identify potential problems that need to be addressed.

• In process:– Pocket cards/algorithms that address medication issues specific to the

older adult.– Consent form for use of antipsychotics in older adults with dementia.

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Example Medication Reconciliation List

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Name: SSN: Date: Allergies:

Bring ALL medication or a current medication list to every medical appointment.

Medication Reason Morning Noon Evening Bedtime Special Instructions

Aspirin 81mg tablet Heart 1 tab Buy at your local pharmacy

Metoprolol 100mg tabletHeart, Blood pressure

1 tab 1 tab Take about 12 hours apart

Lisinopril 10mg tablet Blood pressure 1 tab

Simvastatin 40mg tablet Cholesterol 1 tab

Metformin 1000mg tablet Diabetes 1 tab 1 tab Take with food

Donepezil 10mg tablet Memory 1 tab

Memantine (Namenda®) 10mg tablet Memory 1 tab 1 tab

Geriatrics Clinic Pharmacist: Kristin Phillips, 734-XXX-XXXX


Medication Issues Specific to Older Adults

• Physical impairments (vision, hearing, dexterity).– Provide information in more than one format.– Always have patient repeat instructions back.– Be aware of limitations when prescribing medications (e.g., eye drops

for patient with Parkinsons).

• Cognitive impairment.– Identify reliable caregiver when possible.– Be aware of limitations when prescribing medications (e.g., inhalers).

• Potentially inappropriate medications.

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Success and Challenges

• Evaluation of interventions

– Post clinic visit phone call

– Frequent appointments

– Assess patient understanding

• Challenge

– Cognitively impaired patient self-managing medications• Solutions

– Short-term visiting nurse to assist.– Referral to HBPC or other existing VA resources.– Close clinic follow-up.– Social work involvement.

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Transitional Care Clinic: Value Added to PACT

• Dedicated pharmacist for small panel of patients.• Time provided for prep work on the day prior to appointment.• Seamless integration between disciplines.

– All in same physical location, discussion occurs while the patient is still there.

• True medication reconciliation.– Medication list updated prior to beginning of visit for provider (based on chart

review).– Discussion with provider/team after patient is seen for med review.– CPRS orders are updated, discrepancies resolved.– Patient leaves with accurate list.

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Opportunities to Integrate a Successful Model within PACT – Lessons Learned

• Carve out sufficient time for chart review prior to seeing or communicating with the patient.

• Develop relationship with providers.• Attempt to coordinate appointment on same day as provider

appointment.• Ideal to have face-to-face contact with patient and/or

caregiver, including review of medication bottles.• Have patient fill in blank medication sheet while waiting.• Give direct contact information.

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THE END• Questions?

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