The Essentials of Medication Reconciliation in Home Care

Melissa Mills, BSN

You enter the home of Mrs. Jones to do her start-of-care OASIS assessment. You chit-chat with her before diving into your nursing care. She tells you that she was just released from the local hospital yesterday. She was admitted three days prior for a respiratory infection and exacerbation of her COPD. While in the hospital they started her on steroids, which increased her blood sugar. She tells you that she's not even sure what medications she is supposed to be taking any more.

As you get out your stethoscope and other necessary equipment, you ask Mrs. Jones to gather the pill bottles of all of her medications -prescription and nonprescription - that she is currently taking. She shuffles off to the next room and comes back holding a box of pills that date back to the Obama administration. You silently ask yourself where you even start.

You pull up the discharge papers to see what medications the hospital instructed Mrs. Jones to take. However, when you compare this to what she hands you in the box - it's almost an entirely different list.

Every home health nurse has experienced some version of this scenario. Transitions of care provide many opportunities for medication discrepancies. In fact, a 2014 study published in the Lippincott Nursing Center reports that up to 94% of patients transitioning from the hospital to home care experience at least one medication discrepancy. To combat these issues, all patients being admitted to home care services must have a thorough drug regimen review and medication reconciliation.

What is Medication Reconciliation and Why is it Important?

Medication reconciliation is the act of identifying the most accurate list of all medications a patient is taking. The list should include the name of the drug, current dose, frequency, and the route of administration. This list of medications must be shared with the primary physician to ensure that the patient is taking the correct medications per physicians orders.

Patients are living at home longer than ever before and managing multiple chronic illnesses. Many times, this means they are on several medications and require frequent titrations or drug regimen changes. Without proper medication administration patients are at risk of exacerbations of their health conditions, admissions to the hospital, and even death.

According to the Centers for Disease Control and Prevention (CDC), 3.8 billion prescriptions are written each year in the United States. One of every five new prescriptions are never filled, and of the ones filled, only about 50% are taken correctly. Non-adherence to medication regimens results in approximately 125,000 deaths due to cardiovascular disease each year. It's also estimated that about 23% of nursing home admissions and 10% of hospital admissions could be avoided if patients took their medicines as directed.

Because many home care admissions happen directly after discharge from a hospital or other inpatient facility, the risk of medication non-adherence is high. Home care nurses are in an ideal position to help patients get on the right track with their medications following discharge. Assisting patients with their medications starts with reconciliation.

Reconciliation: A Three-step Process

To complete a thorough medication reconciliation process, you need to follow this three-step process. While it might seem simplistic, in home care many times, this process can take a few days and several phone calls to get straight. The diligence of home care nursing staff is essential when rectifying medications with one or more providers.

Verify the List of Medications

In the story above, you took the first step to verifying Mrs. Jones medications. By asking the patient to bring you the bottles of all prescription and non-prescription medicines they take, you're initiating the process of obtaining the most accurate list.

Be sure to specifically ask for non-prescription medications like headache relief pills, vitamins, and other supplements as some of these drugs can interact with other medications they might be taking. Elderly patients might not consider vitamins or herbs as part of their "medications,” so be specific that you want to see everything they take.

Clarify the List

Once you've created a comprehensive list of all medications the patient is taking, you need to check for any possible drug issues. Pay particular attention to:

Duplicate Drug Therapies - Some patients require multiple prescriptions for the same condition. This can place them at an increased risk of experiencing severe side effects. It's critical that you note examples of duplicate drug therapies and how it might be affecting the patient during your assessment.

For example, if you're performing medication reconciliation and notice that a patient is on three pills for high blood pressure, you want to dig a bit deeper. Some patients need this type of duplication in therapies to get a combination effect. However, if your patient tells you that they were put on the medication three years ago and since then have lost 60 pounds and that they experience dizziness with position changes - you're going to want to communicate this with the care provider right away.

Potential for Interactions - Most electronic medical records have a built-in medication interaction checker. If you don't have an electronic documentation system, you can use an online drug interaction checker like those found on Drugs.com or Rxlist.com.

Enter all of the medications and check for adverse, major, moderate, and minor drug interactions. Educate the patient on the signs of a drug interaction and what to do if they think they are having one. You need to communicate any potential serious interactions with the prescribing and primary physicians, too.

Reconcile the Medications

Once you have a comprehensive list, it's time to reconcile. If there are no duplications or potential drug interactions, the list can be sent to the physician usually via fax. However, if you identify any potential issues you need to notify the physician within 24 hours of finding the problem and have it resolved. This means that the doctor needs to respond to you so that you have an accurate list of medications for the patient.

If you fax or email this communication to the provider, be sure to communicate clearly and concisely what you need from the physician. For example, instead of sending a list of meds and expecting the physician to find the potential issues, send the list and then add in a few bulleted items that clearly state what the problem is and what you need from the doctor or their staff.

Fulfilling Your Essential Role

The role of the home health nurse is crucial for the health and wellness of their patients. You might be the only person who is taking the time to review medications and answer questions for your patient about their medication regimen. Take the time to do a thorough medication reconciliation with every OASIS visit to keep your patients on the path to health.