Elisha Jewett, MPH
In a recent CDC study, 48.9% reported using one or more prescription and 23.1% reported using three or more prescription drugs in the past 30 days. These numbers tell us what those in the healthcare industry already know: most patients are taking at least one medication. As the number of medications that a patient is prescribed goes up, so does the complexity of managing care on both the patient and practitioner/care team and the possibility of medication errors.
As we focus on successful comprehensive patient care, medication reconciliation has gained ground in primary care, with a goal that each patient has a singular, complete patient medication list. Ultimately, an ideal end result is to ensure that all medications are correct and to prevent unintended changes or omissions of medications.
Where should the process of medication reconciliation start?
Typically, medication reconciliation is associated with the inpatient setting and obtaining a patient’s medication list at the time of admission. However, how can we engage in effective medication management as part of integrated or coordinated care?
Primary care is the backbone of an individual’s healthcare, and therefore, an important place for sound medication reconciliation processes to occur. However, the problem is that medication reconciliation is not always done as well in primary care as it should be, for reasons that include: reliance on patient self-reported information, time and training limitations of practice staff and providers, and a lack of communication during transitions of care. It is not enough to write a prescription, educate the patient, and hope for the best; practices need to know what their patients are and are not taking, by using effective, thorough medication reconciliation processes.
Studies indicate that pharmacists are especially effective at medication reconciliation and can significantly improve medication list accuracy during patient admission and/or discharge. For this blog, Dr. Mary Onysko, PharmD of Swedish Family Medicine/University of Wyoming and Dr. Jody Beach, PharmD of Inspira Health Network provided valuable perspectives on skills and approaches pharmacists use in medication reconciliation and opportunities to improve medication reconciliation in primary care.
When should medication reconciliation take place in primary care?
Life events are common for patients between visits, even in short periods of time. For example, a patient may see another healthcare provider, experience a change in health status or have a life change that impacts their ability to access or prioritize medication. As a result, medication reconciliation should be a part of every office visit. If that is not possible in your practice setting, Dr. Onysko suggests certain patient and visit types where primary care practices might prioritize their time spent on medication reconciliation:
- During and/or following a transition of care
- New patients coming to the office
- Patients with polypharmacy
- “Super utilizers” of care
- Provider gut feeling on patient need and confusion
Whose role is medication reconciliation in the primary care practice?
Medication reconciliation is a team-based care activity. Practitioners and pharmacists should be responsible for medication decision making, but other team members can and should be engaged in maintaining updated medication lists to optimize use of staff resources. Two important elements for success are a clinical background and providing training on how to conduct thorough medication reconciliation using probing questions. Practices should also leverage EHR functionality, develop task lists, protocols, and policies and procedures to guide staff in medication reconciliation activities and make the process as simple and easy to follow as possible. For example, following a written protocol, a trained medical assistant (MA) can routinely conduct comprehensive medication reconciliation with patients during the rooming process or telephonically using standing procedures, particularly following discharge from an inpatient facility.
An MA trained to conduct medication reconciliation can note potential side effects, errors in the patient list such as omissions, old prescriptions that have not been removed, differences in how patient takes medication from prescribed, and need for education and self-management support. Then the provider can follow-up with the patient to make any changes or adjustments to their medication regimen.
Dr. Onysko works with medical assistants in her primary care practice to support medication reconciliation. Onysko explains the importance of a team effort so it does not just fall to one person: “Medication reconciliation can be done by just about anyone [within appropriate scope of their training and licensure] if given the time and skills to do it.” She encourages staff to ask probing questions to gather complete and accurate information on patient medications and how they are taking them.
Dr. Beach also encourages staff to lead with questions; see examples of questions. Beach highlights that clinical care team members can utilize their clinical background and be highly effective in getting the complete picture of prescriptions and actual medication use or misuse of patients and their medication history.
Ultimately, it is important to ensure that care team staff have the skills and tools they need to conduct an effective medication assessment and reconciliation. It should not be an assumed part of their existing skill set. Additionally, patients may require the involvement of a pharmacist or practitioner to adjust medication or identify opportunities to improve a medication regimen or care plan.
How you engage patients in medication reconciliation?
There are many ways to engage in medication reconciliation. While often professionals rely on phone conversations at the time of a care transition, in-person visits at the practice or in the patient home are the best opportunity to conduct true medication reconciliation with the patient.
Dr. Beach explains that seeing patients in the home is most helpful. You can learn a lot about the patient by seeing where they live and their living conditions, if they stockpile meds, and other circumstances impacting their welfare. If home visits are not possible for your practice or in cases where they are not appropriate, Beach’s practice policy is to have patients bring their medications to their office visit. While some patients do and others do not, it is very valuable when they do.
“It is incredible what you can learn when patients bring their medicine to their appointment,” Dr. Beach states. “Asking patients to bring in their medications allows the care team to really engage with the patient, going through their medications and explaining how and when they are taking them. You can open bottles and just look and you will catch things.”
Seeing the actual medications may reveal common and avoidable dangers, such as different pills inadvertently combined into one bottle, moistened pills from leaving hard-to-open “safety” lids off in damp bathrooms, use of expired prescriptions, or indications of under- or overuse of pills based on the date of fill, directions, and amount remaining in the bottle.
How can you effectively ask probing questions?
Medication reconciliation often gets watered-down to either creating a current and accurate list of prescribed medications or focusing on changing a patient’s brand name to generic medication – but it is much more than that. It is important that the care team takes the time to make the medication reconciliation list, and process, useful, informative and engaging for the patient. For example, the care team should include exploring how the patient is taking medications, such as dosage, frequency and barriers. Additionally, an updated medication list should include any medications the patient is taking not prescribed by his/her physician, over the counter medications, and vitamin or herbal supplements, even if only taking PRN (as needed).
Probing questions and statements provide space for a dialogue between providers and patients to occur, as opposed to waiting for patients to self-disclose. Dr. Onysko provided some sample questions and provider tips:
- This seems like quite a few medications; how do you keep track of these?
Tip: Give them “permission” to say if they do not.
- Which one of the medications do you like the most, and which do you like the least?
Tip: Drill down into why. Validate the information they provide.
- How much do each of your medications cost? Give patients “permission” to talk about cost.
Tip: Think about the total cost for the patient each month and how might they be prioritizing their purchases.
- Do you combine your medications when you get a refill and have some left?
Tip: Look to see if they have they combined different types of drugs.
- Do you want to know how your medicines work?
Tip: Some people may want to know, but they may be a little mistrustful. They may not feel the impact so they do not understand. Include in your processes and workflows ways to connect patients with practitioners and pharmacists for more information regarding medications.
How can you best educate patients about their medications?
Patients often assume that providers know the full picture of their health. As healthcare professionals, it is important to educate patients that they are the ONLY ones who know what they are taking and if any additional medications have been added to their regimen.
While it is generally understood that the relationship between a pharmacy and patients is important, it is the role of healthcare professionals to reinforce that relationship. For example, encourage patients to communicate with their pharmacy in advance to provide the pharmacy time to fill or order the medication, as needed. Pharmacists can also help educate and empower patients around their medications, flagging any drug interaction, and reinforcing the importance of filling and properly taking their medication. Also, strongly encourage patients to use only one pharmacy for all prescription medications so pharmacists also have a line of sight to all medications a patient is taking.
In the primary care practice, the care team should develop a non-judgmental, patient-centered approach to medication reconciliation. This means that staff should be trained to avoid assumptions about patient behavior. For example: due to understanding or culture, patients may not grasp the concept behind taking a medicine for the rest of their life. To create a dialogue with these patients, it is important to ask questions such as, “Do you know other people that take medication?” and “What was that like for them?”
Probing questions are great tools to ensure that practitioners and care team members understand what medications patients are taking and if they are correctly taking them. Questions also allow care team members to capitalize on their relationships with patients, engaging them in ways that divulge information that they might not otherwise provide. Additionally, when a patient feels empowered to also ask questions, they will be comfortable navigating the healthcare system and take an active role in their health care.
How can I apply this information into my work?
In an ideal world, patients are prescribed medications that they regularly fill and take as prescribed. However, as you engage in regular medication reconciliation, you start to learn common medications that people do not take properly, so you can really drill down into those. Moreover, you will learn what medications they fill or don’t fill and if they are prioritizing other medications due to cost or a side effect that they haven’t previously disclosed. It also might identify if there are medications that are not necessary for the patient to be taking.
Remember, good medication reconciliation is good patient care—it is foremost a process, one with the patient at the center and one squarely focused on good communication, safety, and effectiveness.
Dr. Onysko reinforces this key message in her practice: “Don’t assume that your patients understand why they are taking their medicines.” She suggests that you be very intentional about explaining why you are adding a new medication, how they work together with existing medications, and ultimately, how they benefit the patient.
Credits: A thank you to Dr. Mary Onysko, PharmD of Swedish Family Medicine/University of Wyoming and Dr. Jody Beach, PharmD of Inspira Health Network for their time and insights that made this blog possible.