Good afternoon, everyone. I also would like to take a moment and thank ASLD and the members or the organizers within the Associates SIG for the opportunity to participate in this session today. I have nothing to disclose. As Amanda just reminded us, hospital readmissions are a significant burden to individuals, including those with liver disease, as well as our healthcare system. Pharmacotherapy is an important cause. As demonstrated in a recent review published last year, which looked at both the prevalence and preventability of drug-related hospital readmissions, these studies, in these studies, they found that the rate of readmission due to drugs ranged, varied from 3 to 64%, and the median of 69 of these events were preventable. So that's a big number. Medication errors, as we know, are frequent, with more than half of them occurring during care transitions. So that's including at discharge. And medication errors have been demonstrated also to contribute to hospital readmissions. Medication reconciliation has been recognized as a medication safety initiative to target the burden of these medication errors and the potential harm to patients. And this is really what I'm focusing on today. There are other initiatives, if you will, to help get medications straight, right, before you discharge from the hospital. But if medication reconciliation isn't done, it's the critical step, just because you bring medications to a patient before they leave, if it's not the right medications, if they don't know how to use them, it's not going to be an effective strategy. So we're going to focus here today on medication reconciliation. Specifically, I'm going to provide an overview, define it, go through the steps, highlight some of the common challenges we see in practicing medication reconciliation, and then finally some strategies to improve. Medication reconciliation is a process of comparing medications that the patient has been taking or that they should have been taking with new medication orders and resolving any discrepancies. Medication reconciliation should be done at every transition of care, when a new medication is ordered or existing orders are rewritten. Our goals are to obtain and maintain an accurate and complete medication information for the patient, avoid any medication errors, and then use this information within and across our care continuum to ensure safe and effective medication use. I put this here to remind me, by a show of hands in the audience, how many of you do medication reconciliation as one of your responsibilities? Okay, don't put your hands down yet. So for the next question, how many of you think you do it right? You know how to do it and you do it right. Okay, it seems like the majority have your hand raised. I think I do it right also. I learned some things going through this today. So some of this may be things you know, but we probably haven't gone back over the steps in quite some time. So hopefully it can be a helpful reminder to you as well. So in terms of defining the steps, depending on which organization you look at, they say it different ways, but I'm going to step through it using the steps that the Joint Commission uses, of which there are five. When you think of medication reconciliation, how you perform it at different parts of the care vary, right? So what you do when someone's admitted versus discharged is going to be a little different. So I'm going to try to focus on discharge, oh, I made a new word, medication reconciliation for this talk. So the first step is to develop a comprehensive list of current medications, and second, to develop a list of medications to be prescribed. I just put those together in my mind, and I'm collecting medication information. This is the medication history of the patient. Of course, it includes prescription medications, but we must also have over-the-counter vitamins, nutraceuticals, or health supplements. This is one that can be hard. We might not have time. We kind of just skip it, but you got to ask these questions. In addition to the list of the medications, of course, we need all the details about them, right? It's a little time-consuming, but it's part of the medication history. With medications prescribed, again, this is medications that are prescribed at discharge, right? So you're looking at all the medications. Often we might see the ones that are prescribed for the acute issues of that hospital admission, but we also need to put those in context with the chronic conditions and the other medications they were on previously. We need to make sure that they're prescribed according to evidence-based guidelines, and then, of course, take in the specific characteristics of that patient, right, for these medications. Next, we're going to compare. We're going to compare the initial and updated medication lists, and the purpose here is to really avoid therapeutic duplication as well as address any medical condition the patient may have. Therapeutic duplication happens frequently in a hospital setting where we're required to use specific formularies, right, in medications. The most common one I think of is proton pump inhibitors. You might have them on imeprazole in your institution, but they have pantoprazole at home. Do they use the same one? Do you switch them back? You need to make sure that's clear. Next is the reconcile step, making clinical decisions pertaining to what medication should be continued. This allows us to proactively think about drug-drug interactions, adverse drug reactions, how complex is their regimen. Anything we can do to simplify the regimen will help facilitate appropriate use for the patient as well as adherence. And finally, communicate. This is the huge step, and one I think we're good at doing the other ones, and sometimes we forget this one. When we communicate, we mean with the patient, with their caregivers, as well as the other health professionals. And communicate is not just, hey, look, these are the meds you're on now. It's why did the doses change? What was on hold? What did you change? It's all that medication changes that happen that we need to communicate. So four steps in my world is collect, compare, reconcile, and communicate. It sounds pretty simple. We all have heard it. We think it. However, we all know it's rather complex. It's hard to do. It's hard to do within our day-to-day life, and there's many, many challenges. When I was reviewing for this talk, there's a lot of articles and data, but as I was going through it, I'm not sure how much would resonate with each one of us because our practice sites are so different. So what I tried to do is just kind of take some big picture things in terms of challenges as well as the strategies, and then hopefully at the end, you can take that information and figure out how you can best apply it at your own center. So in terms of challenges, first is the process. This is huge. How can we do a stepwise process if there isn't one? Oftentimes, it's not defined. And if it is defined, it may lack standardization, right? This is always happening. Think about it. Think about that. It's not standard in terms of who does it, who does what step. It's not standard by the different units in the hospital or even the person. I mean, one day, they may do a really good job, but next week, they kind of didn't do it at all. So lack of standardization makes it really tough. In terms of the medication information, our patients are complex, right? They're on lots of medications. There could be lots of changes just during that admission, right? They had a reason something was wrong that they required an admission, so there's probably some changes happening. The information can be unclear. You're looking through your medical record and nobody wrote the reason they put them on this or why did they stop it. It's unreliable. How many times does everybody cut and paste things in our record? We don't know. It could be based on that admission med reconciliation where the patient doesn't really remember or if it's missing because the patient never brought a list, nobody knew what they were on before. They haven't been in your hospital for five years or ever. So it makes it quite challenging. Speaking of our care team, purpose is a really big one. Medication reconciliation is a safety function. It's not a regulatory function. Sure, there is part of regulations, accreditations in a hospital that require it, but the purpose is safety. I think making sure all of our team members understand that is key because that's how you're going to perform the task if you think about it from a safety perspective. Our care teams often are inadequately trained. They lack education. You might not be able to list the steps, but you should kind of be familiar with them. There's really a big amount of confusion in terms of the clinician's roles and responsibility. Who does what? You may have multiple people doing the same thing. You could have a physician take the medication history, a nurse take the medication history, but if they put them in separate parts of the chart and they're not even looking at them, what's the point, right? It's two people doing the same task and they don't communicate. Of course, time constraints and insufficient staffing makes it challenging to do this. System. Systems issues are huge. We could talk about them all day. A lot of the issues I talked about could also be systems issues. So when I think of system, I'm really thinking about the electronic or the medical record for the patient. So I thought easiest to just give a couple examples. I made this real big. I'm not sure if you can see it, but those of you who have Epic, this looks familiar. It's probably similar to other records, systems. So this is just the list of the medications, the directions for use, and then on the right are the checkboxes, taking, not taking, and unknown. So when you perform medication reconciliation, you mark, you ask the patient, and you do this. So two of these medications, Sertrazine and Monolucas, I marked not taking because the patient wasn't taking them. After I do the med rec, I go to put my note in, which then my note goes to the team. This is what the patient's on. Well, you can see Sertrazine and Monolucas are still in the medication list. They're in the medication list because not taking doesn't remove it. You have to put discontinued. Systems issue. Why would the system be built that way? Well, it is. So we have to do discontinued if somebody's gonna use your note and base it on moving forward. So those are things about everybody's individual systems you need to make sure you understand. Another example, this is also a med rec. I marked it on the bottom, marked reviewed, and I'm ready to go to the next step, but you can see the checkboxes aren't done. So how can a system let us go to the next part without completing the tasks there? So that's a systems issue. This could also be other issues, right? There's no process. Maybe I didn't know what I was supposed to do. I'm not educated on it. I didn't have time to do it. Or maybe I just think it's regulatory, right? I mark, hey, I checked it, so that's all I need to do. No, we're not doing the safety piece. So systems issues are a large one, and you really need to try to understand the issues at your center to make sure that you're taking them into account when you're performing med reconciliation. Excuse me. Thinking about the patient, many, but I'm also focusing on at discharge. Health literacy, the language barrier. They lack self-management skills. They don't really know how to manage their medication. Think about it. They've been in the hospital. They might not have motivation to listen to you. They just want to go home. They know the discharge orders are there. They may lack caregiver support, or maybe the caregiver's just not there. How can you discharge them and talk to them about it when nobody's there? And then, of course, the medical condition. As we all know, with a liver disease patient, commonly they're older. They're on complex medication regimens. As we know, you have a high pill burden, dosing frequency, requirement to titrate the medications to symptom and effect. There's an increased potential for drug-drug interactions, adverse effects, the complications with cirrhosis, their comorbid conditions. Example, we all hear all the time about those with encephalopathy. I mean, we're having them titrate. How do you explain to somebody how to titrate? I mean, you're not writing down directions. They have to kind of use their mind and figure it out, or they can't remember. So again, there's a lot of things with our patients that make this even more challenging. We reviewed some of these challenges just in a general sense. At this point, I want to switch over and talk about some strategies, again, in a general way, but I think I picked ones that are, I think, most common for most of us, and hopefully things that you could potentially use at your center. I tried to make some illustrations, so hopefully this will work. So one of the main ones is defining the roles and responsibility of team members. This is one that, at my center, we struggle. We struggle with it even amongst pharmacists doing different tasks. So we collect, we compare, and we reconcile. So who does it, right? There's no specified rule or regulation that a pharmacist has to do it, or a nurse, or whomever has to do it. There's many members of your team that can do it. You have to figure out what's the best for your situation. When, we said at discharge, but what does that mean, right? You have to define it. Discharge is once discharge orders are written. So if the orders aren't written yet, and you're already starting, you could be reconciling meds that aren't even the final meds, so you can see that would be a problem. Next part is what. What do we need to do? So here's where I'm gonna go through a few examples. So you have a team member that you've identified individually completing med reconciliation, right? They go through all the steps. Seems like it works, as long as they communicate, no problem. This is an example of something that came up for us a few months ago, and we're still in the performance improvement piece. That was my person, A, sorry, that was doing all the steps. So on the next one, let's have three people. So this is a transplant, a post-liver transplant patient in the hospital getting ready to go home. The diabetes educator, the pharmacist, and the attending provider are three members of our team working with the patient about their medications. So the diabetes educator educates. This patient didn't have diabetes, so really they have medication-induced blood sugar abnormalities. They're educating them on how to use insulin. The patient is going home from the diabetes educators, they have an education session on 25 units in the morning and the evening. They have a really nice education sheet they give the patient. The pharmacist comes up with a different dose, and it's 35 units in the morning and the evening. This is on our medication card that all patients have and are told to only follow the medication card. Then we have our attending provider, and they gave 30 units in the morning and the evening. This is what is put as the final order in Epic, and then prints out on the discharge information for the patient. So if you're the patient, what do you do, right? Well, this patient decided to look at the diabetes educator sheet, and that's what they followed. So the patient had extremely high blood sugars. They didn't require readmission because they were seen in clinic shortly after, but it potentially could have been a problem. Not to go through the details in much detail, I guess, here, but the diabetes educator performed their education two days before discharge, and that happened to be the insulin the patient was on at that time, so they used it as an example. The pharmacist, what we do is we actually have a protocol or a guideline, and the way you determine how much insulin a patient goes home on is based on the 48 hours of insulin requirement prior, and in the 48 hours since the diabetes educator taught them, the patient was eating, and their insulin requirement increased. The attending provider decided at the last minute that 35 just sounded like a lot, so they went down to 30. So here we have three different ways. So the key here is multiple people can do it, but you have to have a process for these people to communicate, and then ultimately, how to get that information to the patient so it's clear. So imagining multiple people on your team performing this, in this scenario, that communication piece needs a change in the process, right? So what we have to do is figure out how can we make sure that these individuals are doing what they need to do, communicating amongst one another before they talk to the patient. A couple other strategies, in this third strategy here, we have two different people on the team that could potentially perform this function. There are many articles and reviews showing how this is effective. This collect stage can be performed in data supports by pharmacy technicians and pharmacy students. They are actually spending time going over the medications, collecting all that information from the patient, reviewing histories, and have kind of the history done for then the next person to go on and perform the rest of it. And the data has shown that they do it well, and it does allow for medication reconciliation to be completed correctly more times than it was prior to that. Another scenario is, again, using somebody to do the collection or the history part, someone else to do the med rec, and then having one person do the communication piece to the patient, which helps them to clarify and smooth that transition so they're only getting one source of information. So multiple ways to do it. Again, communication amongst the patient and the team is key. Another way to improve strategies is to standardize your medication, whether you call it a form, a card, a list. So the way the patient manages and keeps track of their medicines, standardize the way. Often patients have something that's center specific. You develop it at your centers, you encourage patients to use it. At our center, this is just an example of a medication card that we use post-transplant. It's on paper stock, it's hard, card stock. It is organized by drug types, it gives the opportunity to have directions, it allows us to use it to check boxes based on the slots in the pill box, lots of things with it. We found that a standardized form, everybody starts this way after transplant, is what works. We need to help the patients, we just give them a system to use in the beginning. Other options are computer templates, there's many of them. Some centers, you have a computer template. We've tried to do what we had in that card in our electronic health record, it just doesn't work. We could set it up, but to revise it and do it over time, it's very time consuming. There are other organizations that have some forms. I have a couple examples of these here. I didn't pick one over the other, just a couple to show you. This is from ASHP, which is a pharmacy organization. It's right online, the patient could go in, fill this out, it will save it, they could just update it, user-friendly information. The card or the page organizes it by the time of day they're gonna take it, it allows them to write what it looks like, why they started it, information about it. Another option is from the AHRQ, and it's how to create a pill card. This is very elaborate. There's a 10-page information sheet. The patient needs to have a color printer. They need to know how to use SmartArt and graphics and pull it in. You can have the size, and it looks really nice. I mean, there may be maybe 1% of my patients that could do this, but it's a good idea. So the point is, is there's options out there and they're different for everybody and what you could use. This may help certain people, but we, as the care team, may have to really help set this up, right, for the patient. Another couple I wanna mention is electronic health record. I mentioned for us it's not necessarily useful. The other way to think of it is from the patient's perspective. In Epic, there's MyChart, and others, there's other ones where the patient can log on and see their information. Well, in MyChart, a patient can go in and modify, like, oh, I'm not on that dose, oh, I stopped taking this, but it doesn't really take it off forever. It doesn't take it off until we, the providers and the care team take it off. So the patient thinks they adjusted it and then they come to you and they're like, but I already updated it. So it's not really useful. Phone apps are great for reminders, great for adherence for patients, but in this situation, not so good. I mean, can you imagine it discharged to the patient? Oh, I have it on an app, here's my list. Can you update it for me? Or some apps can email it. Well, then they email it to you. How are you gonna stop what you're doing? So for this, it doesn't really work, in my opinion. No matter what you have them do, directions. You gotta have a standard directions. You'd want them to create a list, a card, a form, to keep track of all their medicines. You want them to have it with them, and you're saying at the hospital, at emergency room, outpatient, laboratory, always. Update it, we tell them with a pencil, so then they can erase it. If not, they do it with pen, then they come back and they say, can you make me a new one? So if they do it with pencil, it makes it a little bit easier. Add comments, have their caregivers work with it, and always let them know to ask you for help. So regardless of what you do, you wanna make sure it meets the patient's individual need. It's consistent with their health literacy, and it's in their native language. We let patients, as time goes on, and they have a system down, if they wanna change the way they manage, that's fine, as long as they have a list and can manage their medications. Once they have a list, you could implement this teach-back method. I know we've probably all heard it, but it really allows open-ended questions to go back and forth with the patient to see if they really do understand their medications, as well as help you identify what questions they may have. Communication strategies, we've talked a lot in terms of the team, how to set it up to communicate with each other and the patient, but we need to think of the others. That's another part of that last step. So other healthcare providers, pharmacists in the community, other electronic health records, and how do people read what you put in there, as well as the caregivers. A couple articles I just wanted to quickly state in terms of team education. We know that medication reconciliation decreases errors. However, there's lacking formal training in most places. This one study provided education intervention for medical residents. They taught them very briefly within their medical training, and then they assessed discharge discrepancies and found an improvement in four of the five. Very simple to put in, but maybe standardized testing, I mean education. Another strategy is in terms of electronic tools. Many, many articles on this. This one was interesting, this was with pediatrics, but they had an automated email reminder linked to the health record. So if a patient's medication reconciliation was not completed within 24 hours of an admission, an email from the hospital director went to that admitting resident and said, hey, you need to finish it, and they found a decrease, a significant decrease in the ones completed. Sounds like it might be hard, but it's a nice reminder. Again, if your admission med rec is done, and done hopefully well, think how much easier that makes your discharge medication reconciliation. We went through a lot globally, and again, as I've mentioned, really identifying challenges that are specific for your center are what you need to do. So once you've identified them, what can I help you with, what do you do? Data, all these things that you identify, you wanna have data. The way you engage your stakeholders and get people to listen to you is to have data. If you just say, hey, I could make me save five minutes, people might not listen to it, or oh, I could make this form prettier for the patient. You really wanna have information data-driven about a challenge, or maybe an error that was committed. And then I think set it up as a performance improvement initiative is helpful. I know I only have a couple minutes left, but briefly, just to let you know, there is a consensus statement that was published in 2010. And it's detailed, but it has steps. It goes through it, it's a great resource. Also, there's a Medication at Transitions and Clinical Handoff, or MATCH, toolkit. I don't know if anybody's familiar with it, but it also has the steps, so it goes through gaining leadership support, building the team and the scope, defining the process, how to implement it, how to educate and train, and then how to assess and monitor that process. This is maybe 80 pages, but it's also online. You can click on each of this. It has flow charts, it has, I mean, it's very, very detailed, but for those of you that find a specific area that maybe your center needs improvement on, this could be a great tool to help you do that. So, quickly, we went through all the steps of med reconciliation, reviewed some of the challenges, and identified some strategies for improvement. Some final tips or recommendations I'd like to leave you with is to appreciate that med rec is a medication safety function rather than a regulatory one. To know and understand the steps, collect, compare, reconcile, and communicate. And communication, I think, is the huge one, and the one that we really need to do better to help improve our transitions of care. Realize your role and responsibilities in the process. Identify related challenges, and identify problems areas at your centers, right? One size doesn't fit all. And finally, to implement targeted med rec improvement strategies to reduce preventable drug-related hospital re-admissions to ultimately improve patient care. So I'd like to thank you for your attention, and I'll be happy to answer questions during our panel. Thank you.

medication reconciliation

hospital readmissions

liver disease patients

challenges

strategies for improvement

data-driven performance improvement