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Is 3rd leading cause of patient harmMedical errors - 8th leading cause of death in the USEach year in the US est 450 000 preventableEach year in the US, est. 450,000 preventable med-related adverse events occur20% of patients have complications within 3 weeks of DC from hospitalAdverse Drug events are most common problem

Medication errors are the most common type of medical error and lead to:◦ Disease exacerbation◦ Increase in re-hospitalization◦ Higher utilization of acute and outpatient careHigher utilization of acute and outpatient care

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The comprehensive assessment must:Include a review of all meds the patient is currently usingIdentify any potential adverse effects and drug reactions including:◦ Ineffective drug therapy◦ Significant side effects◦ Significant drug therapy◦ Duplicate drug therapy◦ Noncompliance with drug therapy

JCAHO National Patient Safety Goal: Maintain and communicate accurate patient medication information.

Rationale: Medication discrepancies can affect medication outcomes. Medication reconciliation is intended to identify and resolve discrepancies.

Elements of Performance:◦ Obtain and/or update information on the

medications the patient is currently taking. This information is documented in a list or other format this is useful to those who manage medications.◦ Define the types of medication information (forDefine the types of medication information (for

example, name, dose, route, frequency, purpose) to be collected in different settings and patient circumstances.◦ Compare the medication information the patient is

currently taking with the medications ordered for the patient in order to identify and resolve discrepancies.

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Elements of Performance(continued):◦ Provide the patient(or family as needed) with

written information on the medications the patient should be taking when he or she leaves the organization’s care(for example, name, d f )dose,route,frequency,purpose).◦ Explain the importance of managing medication

information to the patient.

M2000 Drug Regimen ReviewM2002 Med Follow UpM2004 Med InterventionM2010 Pt/Cg High Risk Drug EducationM2015 P /C D Ed i I iM2015 Pt/Cg Drug Education InterventionM2020 Management of Oral MedsM2030 Management of Injectable MedsM2040 Prior Med Management

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Management of Oral Medications: Patient’s current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. (NOTE: This refers to ability, not compliance or willingness.)0 – Able to independently take the correct oral medications and proper dosages at the correctmedications and proper dosages at the correct times1 – Able to take medications at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart2 – Able to take medications at the correct times if given reminders by another person at the appropriate times3 – Unable to take medications unless administered by someone else

If the patient does not have her prescribed medications in the home because she cannot afford them and she does not plan on getting them, what is the most appropriate response for M2020?for M2020?

When answering this question you are reporting the patient’s ability to take all meds reliably and safely at all times on the day of the assessment. If the patient did not take her medications on the day of assessment because they were not present in the home, you CANNOT make assumptions about a patient’s ability to take medications sheabout a patient s ability to take medications she doesn’t have. If the meds were not in the home, you would not be able to determine if she could take each med at the correct time and dose. The patient’s status would be reported as “3-Unable to take medications unless administered by another person.”

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◦ The process of identifying the most accurate list of all medications a patient is actually taking—including name, dosage, frequency, and route. The information is then used to determine which medications the patient should be taking per physician orders.

*Adapted from CHAMP (Collaboration for Home Care Advances in Management and Practice) and from the Institute for Healthcare Improvement

Medication Reconciliation Process◦ Verify- Collect an accurate medication list

COLLECT and VIEW all the medication bottles including OTC, herbal products, dietary supplements and vitaminsE h i h di i li dEnsure the patient has an accurate medication list and verify against physician orders

◦ Clarify- Clarify any questions about drug/dose/frequency/route◦ Reconcile- Communicate with physician about any

identified medication questions or concerns

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AdmissionTransfer to another facility or providerDischargeAfter medical appointmentsAny new or changed medication order from physician

At SOC, did someone TALK with you about all of your medications

At SOC, did someone ask to SEE all of your , ymedications

In the last 2 months:◦ did you have any new or changed medications?◦ did someone talk with you about the purpose of new

or changed medications◦ did someone talk with about when to take these

medications◦ did someone talk with about the side effects of these

medications

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HHVNA’s Acute Care Hospitalization (ACH) rate is higher than the national average according to OCS data Sept. 2010 (cumulative score)score)

- HHVNA: 30%- National: 29%

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96% of pts. had 10 or more medications

59% of pts. Had 20 or more medications

One patient had 42 different medications

59% of pts. had admitting primary or secondary diagnosis of CHF or COPD23% of pts. Had re-hospitalization diagnosis of CHF or COPD44% of pts Re hospitalized within 6 days of44% of pts. Re-hospitalized within 6 days of SOC/ROC96% of patients re-hospitalized within 4 days of last clinician visit

89% of pts. were “compliant with POC/meds”78% of pts. predominantly saw primary clinician74% t h d MD t ithi 2 k f SOC74% pts. had MD appt within 2 weeks of SOC22% of pts. called agency before hospitalization45% of pts. were sent to ED by MD

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Educate all staff at Team meetings◦ High Risk Drug List◦ Definition/Process of Medication Reconciliation◦ Oasis medication questions◦ NEW Medication Teaching Sheetg◦ NEW Tip sheet- Things to Say / Things to Do◦ Zone Tool◦ Teach Back Method◦ Best Practices – STAR◦ Telehealth

Drug Classification

Examples of Drugs

Anticoagulants Arixtra (FondaparinuxSodium)ASACoumadin (Warfarin)HeparinLovenox (EnoxaparinSodium)NSAIDSPlavix ( Clopidogrel Bisulfate)

Cardiovascular  Cardiazem (Diltiazem Hydrochloride)Isordil (Isosorbide Dinitrate)Lanoxin (Digoxin)Lasix (Furosamide)Lopressor (Metoprolol Tartrate)Norvasc (Amlodipine Besylate)Tenormin (Atenolol)

Corticosteroids Decadron (Dexamethasone)Medrol (Methylpresnisolone)Prednisone

Hypoglycemics Insulins

Anticonvulsants Dilantin (Phenytoin Sodium)PhenobarbitalTegretol (Carbamazepine)

Antidepressants Elavil (AmytriptylinePamoate)Prozac (FluoxetineHydrochloride)Zoloft (SertralineHydrochloride)

Antipsychotics LithiumKlonopin (Clonazepam)Risperdal (Risperidone)Zyprexa (Olanzapine)

Hypoglycemics InsulinsGlucophage (MetforminHydrochloride)Glucotrol (Glipizide)

Opioids CodeineFentanylMethadoneMorphineOxycodone

Sedatives Ambien (Zolpidem Tartrate)Ativan (Lorazepam)Buspar (Buspirone Hydrochloride)Restoril (Temazepam)Valium (Diazepam)Xanax (Alprazolam)

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Things to SAYAgency Name: Home Health VNAEmployee Name and Title

Explain things in an Easy to Understand wayArrive at what time (within a 2 hr range)

Things to Do

Treat patient with Courtesy and Respect

Check home for Safety( g )

Home Safety ‐ I'm looking around for any safety concernsPainGently (change your dressing, Bend your knee….)

Meds (prescription and over the counter)     1. See them     2. Purpose of taking     3. When to take      4. Side Effects of meds     5. Any New meds Clearly address knowledge of case ‐know what all disciplines are doing!  

Check chart before going into patients so you are informed of care

Arrivewithin the range you said you would or CALL them to and tell them you will be late

Listen Carefully ‐ be attentive 

CHF Zones for Management

Your Current Weight: ______________________ GREEN ZONE: ALL CLEAR

⇒ No shortness of breath ⇒ No swelling ⇒ No weight gain ⇒ No chest pain ⇒ No decrease in your ability to maintain your activity

level

GREEN ZONE MEANS:

⇒ Your symptoms are under control ⇒ Continue taking your medications as ordered ⇒ Continue daily weights ⇒ Follow low-salt diet ⇒ Keep all physician appointments

YELLOW ZONE: CAUTION

⇒ Weight gain of 2 or more pounds in 24 hours or 5 lbs in 7 days I d h

YELLOW ZONE MEANS:

⇒ Your symptoms may indicate that you need an adjustment of your medications

⇒ Increased cough ⇒ Increased swelling ⇒ Increase in shortness of breath with activity ⇒ Increase in the number of pillows need ⇒ Anything else unusual that bothers you

all Home Health VNA 1-800-933-5593 if you are oing into the YELLOW zone:

Call Home Health VNA at 1-800-933-5593 Your Nurse’s Name: _________________________________________________ Instructions: _________________________________________ ___________________________________________________

RED ZONE: MEDICAL ALERT

⇒ Unrelieved shortness of breath: shortness of breath at rest

⇒ Wheezing or chest tightness at rest that is not relieved by medication

⇒ Chest pain not relieved by medication ⇒ Need to sit in a chair to sleep (if this is a new symptom

for you) ⇒ Weight gain or loss of more than 5 pounds in 2 days ⇒ Confusion

all your physician immediately if you are going into the RED one.

RED ZONE MEANS:

⇒ You need to be evaluated by a physician right away

Call your physician right away !

Physician: ____________________________________________ Number: ____________________________________________

Adapted from Christus Schumpert Health System, Shreveport, LA

Overview•Studies show that 40‐80% of the medical information patients receive is forgotten immediately1 and that nearly half of the information retained is incorrect2.•Teach‐back is a way to confirm that what you have explained to the patient what they need to know in a manner that the patient understands.•It involves asking the patients to explain or demonstrate what they have been told.

Teach‐Back Method:•Start slowly: Only give the patient 2‐3 new education items at a time•Keep it simple: Avoid medical terms. Use simple words that anyone will understand.•Plan your approach: Think about how you will ask the patient for teach‐back information based on your topic.•Use handouts: Verbally review/read all handouts to the patient and stress the important information.•Clarify: Clarify your information until the patient can correctly describe in their own words what they are going to do.

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Things to keep in mind: •This is not a test of the patient’s knowledge: This is a test of how well you explained the concept.•Use with everyone: Use teach‐back when you think the person understands and when you think someone is struggling with your directions.•Do not ask a patient, “Do you understand?”•The clinician takes responsibility for adequate teaching: If the patient cannot explain correctly, assume that you have not provided adequate teaching. Re‐teach using an alternate approach.E l f T h B k d iExamples of Teach‐Back education:•“I want to be sure that I explained your medication correctly. Can you tell me how you are going to take this medicine?”•“We covered a lot today about your diabetes; I want to make sure I explained things clearly. So let’s review what we discuss. What are 3 strategies that will help you control you diabetes?”•“What are you going to do tomorrow morning before taking you meds?”•“When your friends/family asks you about this medication, what are you going to tell them?References:•Kessels RP. Patients’ memory for medical information. J R Soc Med. May 2003; 96(5):219‐22.                                           •Anderson JL, Dodman S, Kopelman M, Fleming A. Patient information recall in a rheumatology clinic. Rheumatology. 1979;18(1):18‐22.•Removing barriers to better, safer care, Health literacy and patient safety: Help patients understand, Manual for clinicians, 2nd ed., Barry D. Weiss, MD 2007 American Medical Association Foundation and American Medical Association.

Identify Primary Caregiver/Learner

Teach Back/

HHVNA BEST PRACTICES TO REDUCE RE-HOSPITALIZATIONS

PATIENT

Teach Back/Zone Tool

Front Load Visits Medication Reconciliation

MD Appt.

Revise record audit tool to include assessment of medication reconciliation

Review CAHPS patient satisfaction medication questions and scores on a monthly basisquestions and scores on a monthly basis

Review the quarterly Q and A’s sent out by CMS related to medication oasis questions

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Initiate software update request to vendor for detailed medication drop downs

Monitor ACH results monthly-comparing OCS to Home Health Compare and Casperto Home Health Compare and Casper

Present CQI projects for Medication Management and Reducing ACH to Clinical Management Team and Performance Improvement Committee

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Home Health Compare2012

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Home Health Compare 2012

Identify all STAAR patients on admissionParticipate on STAAR committees in our local area hospitalsWork directly with the Transition Coaches on Medication ReconciliationMedication ReconciliationDevelop effective hand-off communication to and from all referring agenciesUtilize the same educational materials sent home with patient from hospital