Medication Safety and Reconciliation in Homecare

Introduction

Organization’s Vision and Mission Statement

Northwell Health Care System is an organization that serves a network of more than 800 hospitals and care centers. Northwell Certified Home Health Agency (CHHA), which is part of the Northwell Health Care System, provides a range of home health services, including home health aides, medical supplies, occupational and speech therapists, speech therapists, medical and social services, as well as nutritional services. Northwell Health System is dedicated to the provision of quality healthcare services to its clientele regardless of the setting. The provided services are reimbursed by Medicare, Medicaid, and private insurance companies. The vision and mission of the organization are to enhance the health and quality of life of the communities and people it serves by offering world-class service and patient-focused care.

Background of Project’s Impetus

The New York State Department is tasked with monitoring the services provided by CHHAs through quality measures, which are indications of how well home health agencies cater to their patients. Data used to develop the quality measures are obtained from HHCAHPS surveys, Medicare claims, and OASIS. OASIS mandated that federal assessments be completed each time patients under Medicare or Medicaid are referred to home care, following 60 days of admission, and after discharge from the care provided by professional staff. Pharmacological intervention is the mainstay of treatment in most health conditions. The efficacy of this treatment is determined by patients’ adherence to prescription instructions. The incorrect usage of medications often leads to negative events such as polypharmacy, medication errors, adverse drug reactions, and unremitting illnesses, which may warrant the readmission of patients back to health facilities. Such occurrences contribute to poor performance in quality measures used to monitor CHHAs. Therefore, it is necessary for healthcare professionals in CHHAs to ensure that patients take their medications correctly the following discharge from hospitals.

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Literature Review

Medication errors are common problems during the transition of patients from hospital to home-based care (Hale et al., 2015). About 75% of elderly patients aged 65 years and older are usually referred to home health care upon discharge from hospitals (Jones et al., 2017). The probability of medication errors increases significantly during the transition from hospitals to home-based care (Kee et al., 2018). Polypharmacy is a major problem among home-based patients, with some taking more than 12 medications concurrently (Champion et al., 2020). This problem is prevalent among elderly patients due to the likelihood of multiple comorbidities with advancing age. Medication reconciliation is the most appropriate intervention to ensure that patients take all drugs required to manage their health conditions while eliminating duplications (Champion et al., 2020). Therefore, the level of coordination between hospitals and home health care nurses is critical to ensuring medication safety and reconciliation during this period of transition.

The scope of medication errors and adverse drug events has been studied extensively in hospital setups. However, there is limited information about the scope of this issue in-home health and primary care settings (Meyer-Massetti et al, 2018a). Registered nurses in primary care settings report that these errors occur mainly due to reporting inconsistencies, lack of competence, lack of information, trade name products, and varying routines (Berland & Bentsen, 2017). The lack of proper discharge planning affects the transition from hospital to home-based care, which ultimately contributes to high readmission rates due to medication errors, polypharmacy, and adverse drug events among other related issues (Mickelson & Holden, 2018; Zurlo & Zuliani, 2018). Jones et al. (2017) also report that the main challenges faced by home health care nurses, which contribute substantially to medication errors include lack of accountability, poor communication, inadequate assessment of goals, and poor management of medications.

Additional sources of medication errors during home health care include the omission of medications, the administration of wrong administration, wrong time or route of administration, and dosage errors (Parand et al., 2016). Among geriatric patients, age, standards of living, and the nature of prescribed drugs are notable issues (Olsen & Sletvold, 2018). Furthermore, the low usage of medication charts and lack of interdisciplinary medication review have been reported to contribute to this issue substantially (Elliott et al., 2016). The main problems that hinder the transfer of information as noted by the participating nurses include poor medication management, poor communication, patient factors, and technological issues (Meyer-Massetti et al., 2018a; Meyer-Massetti 2018b; Sarzynski et al., 2019). The lack of knowledge among patients is one of the most common patient factors.

Medication safety among patients under home-based care could be achieved by conducting thorough patient education before discharge and improving follow-up communication as part of patient support following discharge (Flanagan et al., 2018). Training caregivers on the handling of drugs as well as providing customized equipment and strategies on a need-by-need basis is among the most effective evidence-based interventions to prevent medication errors (Parand et al., 2016). Additional strategies that have been shown to improve medication literacy and safety among patients include a comprehensive assessment of care conditions, understanding the patient’s expectations, and detailed knowledge of transitional care programs. Medication reconciliation is an evidence-based intervention that has been shown to eliminate the duplication of drugs. Therefore, hospitals and home health care centers should consider medication reconciliation as one of the pertinent issues to be done during discharge.

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There should be effective communication between pharmacists, nurses, and primary care physicians as well as between hospitals and home care settings to manage all medication-related issues in patients (Kee et al., 2018). A study by Foged et al. (2018) showed that e-messaging between primary and secondary care nurses as well as between hospital and home-based care nurses could enhance the communication of medication information, thereby facilitating a smooth transition. The interoperability of electronic medication data can also enhance medication reconciliation (Champion et al., 2020). Therefore, addressing these areas could improve information transfer and prevent avoidable medication errors. These elements would contribute significantly to the avoidance of problems, such as medication errors, for improved patient and care outcomes.

Gap Analysis/ Needs Assessment

As a home care nurse, it has been noted that most patients encounter confusion regarding what medications to take at home following discharge from the hospital. The most common assumption made by patients is that they should continue taking all medications that they took while in the hospital. Such practices often lead to polypharmacy, missed drug doses, and wrong medication doses, which result in negative health outcomes that warrant hospital readmissions. Another negative outcome of incorrect usage of medication is poor patient satisfaction, which impacts negatively on an organization’s reputation and quality indicators. Northwell Certified Home Health Agency has reported numerous cases of medication-related adverse events in its home care patients. These events signify a gap in patients’ knowledge of medication use and the need for home care nurses to fill this void through appropriate interventions.

Project Charter, Scope, and Objectives

The overall goal of the project is to improve medication safety and reconciliation in-home care settings post-discharge. The project covers aspects of medication-related care in home health settings. Four specific objectives have been formulated to achieve the overall goal. The first objective is to improve the medication safety and reconciliation rate by 25 percent by the end of February through the training of field nurses. The second objective is to develop a medication schedule time tool that will increase the patient’s ability to take medication on time and in correct doses by the 20th of December. The third objective is to increase patient participation in medication management by the end of February. The fourth objective is to improve the transfer of medication information during the transition from hospital to home by the 30th of January.

Implementation Plan

Processes and Procedures

The first process in the project will be stakeholder identification. Identifying stakeholders provides a clear understanding of the people who are going to be affected by the outcomes of the project directly and indirectly. As a result, the investigator can work towards clear communication to ensure that the concerns, needs, and expectations of the stakeholders are met. A project may involve different activities in various phases. Therefore, different stakeholders may be engaged at various stages of the project. Identifying all potential stakeholders allows the researcher to provide periodic updates and feedback as required. The proposed stakeholders for the project include home health nurses, patients, their families, and part of the Northwell Certified Home Health Agency administration.

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The second process will be a literature search and evaluation. Evidence-based practice entails gathering, processing, and executing findings from research to improve clinical settings and patient outcomes (Skela‐Savič et al., 2017). The American Nurses Association requires nursing interventions to be feasible, systematic decisions founded on evidence-based research studies. The application of the evidence-based approach in nursing practice promotes the provision of quality and cost-efficient patient care (Skaggs et al., 2018). Evidence-based research will be used in this project to improve medication reconciliation and safety as well as to develop the medication schedule time tool. Peer-reviewed articles will be searched from databases such as PubMed, Google Scholar, and CINAHL. The key search phrases that will be used include medication reconciliation, home health care, and medication safety. The search outcomes will then be filtered to narrow down to full-text articles published in the last five years. The abstracts will be skimmed to identify relevant articles for subsequent use.

The third step will involve training of staff members and the development of the medication schedule and time tool using information from the evidence-based research, whereas the fourth process will be data collection. The final process will be the evaluation of project outcomes. Project evaluation refers to the methodical and objective appraisal of a continuing or completed project. The goal of this process is to determine the importance and extent of the attainment of project objectives, effectiveness, effect, and sustainability. Summative evaluation, which is done at the end of a project, will be used to determine the effectiveness of the interventions and the attainment of project goals.

Work Units, Tasks/Activities

A total of seven activities will be done to complete the project. The first task will be to engage stakeholders to get their perceptions regarding the problem. Home health nurses will be briefed about the issue of medication errors among patients and asked to explain some of the challenges they face and what can be done to address them. Similarly, patients will be asked to state some of the issues they face when taking medications at home following discharge from the hospital. This information will help to customize the evidence-based interventions to match the precise needs of the stakeholders.

The second activity will be conducting a literature search, critiquing evidence, and synthesizing it. A literature matrix table will be used to simplify the process. Key recommendations to guide the project will be summarized in the table. The third activity will be the collection of baseline data on medication errors, polypharmacy, and hospital readmissions associated with medication errors. These data will be critical during the evaluation stage to determine the efficiency of the project and the attainment of objectives. The fourth activity will be the development of the medication schedule time tool using information obtained from the literature and feedback from the stakeholders. The fifth activity will be to train home health nurses on the use of the tool as well as evidence-based strategies for conducting medication reconciliation and ensuring smooth transitions of patients from hospital to home care. The sixth activity will be the implementation of the project and data collection. Implementation will involve the actual use of the medication schedule time tool and medication reconciliation. The final activity will be using the data collected at the end of the project to evaluate its effectiveness.

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Project Deliverables

The main tangible project deliverable is a medication schedule time tool aimed at promoting the correct usage of medication by patients. This tool will be developed by compiling information from evidence-based resources on medication reconciliation and home health care as well as customizing the proposed interventions to suit home health settings. Intangible deliverables from the project include improved medication safety and reconciliation, increased patient involvement in medication management, and enhanced transfer of medication data during hospital-home transitions.

Metrics of Success

Outcome measures at the baseline will be compared to data at the end of the project to determine the success of the initiative. Each specific objective will be evaluated separately. Medication safety and reconciliation rate will be assessed by taking the average rate of reconciliation at the beginning of the study (baseline) and by the 28th of February. The baseline medication reconciliation rate will be subtracted from the average rate of medication reconciliation at the completion of the study. This difference will be calculated as a percentage of the baseline rate. The success of the second objective will be determined by the availability of a feasible medication schedule time tool at the completion of the project.

The success of the third objective will be measured by comparing the levels of patient participation in medication management at the baseline of the project and at the completion of the project. A student t-test will be used to determine the statistical significance of the improvement. The analysis will be done at a 0.05 level of significance using the Statistical Package for Social Sciences (SPSS) version 25. Similarly, the efficacy of the fourth objective will be determined by comparing information transfer at the baseline and the end of the project.

Timeline and Schedule

The first activity that is required to initiate the project is engaging stakeholders followed by conducting a thorough literature review to find evidence-based strategies for medication reconciliation in home-health settings. This information will then be used to create a medication schedule tool that will then be used to contribute to the attainment of the other three objectives. Table 1 summarizes the timeline and schedule of the project.

Table 1: Project timelines

Activity Timeline
Stakeholder engagement 10thof December
Literature search, critique, and synthesis 10thof December
Development of a medication schedule tool 20thof December
Enhanced transfer of medication data information at the transition from hospital to home 30thJanuary
Increased medication safety and reconciliation February 28th
Patient participation in medication management February 28th
Project evaluation February 28th

Budget

Cost-Benefit Analysis

Medication discrepancies can place patients at increased risk for adverse drug events (Hale et al., 2015). Estimates from the organization’s records suggest that medication errors cost Northwell Health Care System approximately $50,000 annually in terms of Medicare deductions associated with hospital readmissions and adverse drug events. The cost of implementing the project is estimated at about $4,500, which would lead to yearly savings of $45,500 if the intervention is successful. Therefore, the financial benefits of implementing the project outweigh the costs.

Resources

Several resources will be required to facilitate the completion of the project. They include time to research, synthesize information, and develop a medication schedule time tool. Time will also be needed to train home health care nurses on medication reconciliation and ease the transition of medication data from hospital to home care. A reliable internet connection and a computer will be needed for the literature search, synthesis, and development of the medication schedule time tool. A projector will be required to make brief presentations during training. However, this resource is already available at the facility and would not need to be purchased. The training process will also require stationary such as pens and notebooks. Printing services will be needed to print out hard copies of the medication schedule time tool. A website hosting fee of approximately $500 annually will be required to add the medication schedule time tool to the organization’s website. This would be a cheaper approach as opposed to the development of a mobile application, which would also take more time. Table 2 shows a summary of the project’s budget.

Table 2: Project budget

Item Cost ($)
Stationery 500
Training 2,500
Printing 500
Tool development 500
Web hosting fee 500
Total 4,500

Risk Management Plan

Risk management consists of clinical and administrative processes, systems, and strategies used to identify, monitor, evaluate, alleviate, and preclude risks. Risk management initiatives help healthcare organizations to safeguard patient safety as well as the organization’s standing, accreditation, brand value, and community standing. The most environmentally friendly approach to the implementation of the medication schedule tool is through the development of an online platform on the organization’s existing website that is easily accessible by patients and home health nurses. However, the key danger of online resources is occasional malfunctions or inability to access them due to poor internet connectivity. Such interruptions could interfere with the medication management process and increase the likelihood of errors. To manage this risk, a paper-based version of the tool will also be developed and availed to patients and nurses. Furthermore, some patients may be more comfortable with paper and pen documentation of medications as opposed to using mobile devices. The availability of the tool in both formats will cater to such patients and mitigate the risk of interruptions in medication management.

References

Berland, A., & Bentsen, S. B. (2017). Medication errors in home care: A qualitative focus group study. Journal of Clinical Nursing, 26(21-22), 3734-3741.

Champion, C., Sockolow, P. S., Bowles, K. H., Potashnik, S., Yang, Y., Pankok Jr, C., Le, N., McLaurin, E., & Bass, E. J. (2020). Getting to complete and accurate medication lists during the transition to home health care. Journal of the American Medical Directors Association, 4, 1-6.

Elliott, R. A., Lee, C. Y., Beanland, C., Vakil, K., & Goeman, D. (2016). Medicines management, medication errors and adverse medication events in older people referred to a community nursing service: A retrospective observational study. Drugs-Real World Outcomes, 3(1), 13-24.

Flanagan, P. S., Briseño-Garzón, A., Zed, P. J., & Strain, R. M. (2018). Safety outcomes with home assessment trial: A mixed-methods evaluation of medication safety in the home care setting. Home Health Care Management & Practice, 30(2), 76-82.

Foged, S., Nørholm, V., Andersen, O., & Petersen, H. V. (2018). Nurses’ perspectives on how an e‐message system supports cross‐sectoral communication in relation to medication administration: A qualitative study. Journal of Clinical Nursing, 27(3-4), 795-806.

Hale, J., Neal, E. B., Myers, A., Wright, K. H., Triplett, J., Brown, L. B., Kripalani, S., & Mixon, A. S. (2015). Medication discrepancies and associated risk factors identified in home health patients. Home Healthcare Now, 33(9), 493-499.

Jones, C. D., Jones, J., Richard, A., Bowles, K., Lahoff, D., Boxer, R. S., Masoudi, A., Coleman, E., & Wald, H. L. (2017). “Connecting the dots”: A qualitative study of home health nurse perspectives on coordinating care for recently discharged patients. Journal of General Internal Medicine, 32(10), 1114-1121.

Kee, K. W., Char, C. W. T., & Yip, A. Y. F. (2018). A review on interventions to reduce medication discrepancies or errors in primary or ambulatory care setting during care transition from hospital to primary care. Journal of Family Medicine and Primary Care, 7(3), 501-506.

Meyer-Massetti, C., Meier, C. R., & Guglielmo, B. J. (2018a). The scope of drug-related problems in the home care setting. International Journal of Clinical Pharmacy, 40(2), 325-334.

Meyer-Massetti, C., Hofstetter, V., Hedinger-Grogg, B., Meier, C. R., & Guglielmo, B. J. (2018b). Medication-related problems during transfer from hospital to home care: Baseline data from Switzerland. International Journal of Clinical Pharmacy, 40(6), 1614-1620.

Mickelson, R. S., & Holden, R. J. (2018). Medication adherence: Staying within the boundaries of safety. Ergonomics, 61(1), 82-103.

Olsen, R. M., & Sletvold, H. (2018). Potential drug-to-drug interactions: A cross-sectional study among older patients discharged from hospital to home care. Safety in Health, 4(8), 1-8.

Parand, A., Garfield, S., Vincent, C., & Franklin, B. D. (2016). Carers’ medication administration errors in the domiciliary setting: A systematic review. PloS One, 11(12), 1-18.

Sarzynski, E., Ensberg, M., Parkinson, A., Fitzpatrick, L., Houdeshell, L., Given, C., & Brooks, K. (2019). Eliciting nurses’ perspectives to improve health information exchange between hospital and home health care. Geriatric Nursing, 40(3), 277-283.

Skaggs, M. K. D., Daniels, J. F., Hodge, A. J., & DeCamp, V. L. (2018). Using the evidence-based practice service nursing bundle to increase patient satisfaction. Journal of Emergency Nursing, 44(1), 37-45.

Skela‐Savič, B., Hvalič‐Touzery, S., & Pesjak, K. (2017). Professional values and competencies as explanatory factors for the use of evidence‐based practice in nursing. Journal of Advanced Nursing, 73(8), 1910-1923.

Zurlo, A., & Zuliani, G. (2018). Management of care transition and hospital discharge. Aging Clinical and Experimental Research, 30(3), 263-270.

Appendices

Project Objectives Mapping Matrix

Student name

In the first column of the matrix below are the programmatic student learning outcomes (PSLOs) for your program. The school has defined these particular PSLOs as what the school wants its students to know or do by the end of their program. These PSLOs have been the foundation upon which the entire program has been built. Every course you have taken as part of this program was designed specifically to help you master these objectives.

In the matrix below you will map the objectives of your practicum project to the PSLOs. Every project objective does not have to map to a PSLO nor does every PSLO have to have something mapped to it, and a project objective can map to more than one PSLO.

A typical project will have 3 to 5 objectives. Enter your project objectives in the headings of each column. For each project object that maps to a PSLO, briefly describe how it aligns with the Program SLO in the corresponding box.

PSLO Objective 1
Improve medication safety and reconciliation rate by 25 percent by February 30 through training of field nurses
Objective 2
Develop a medication schedule time tool that will increase the patient’s ability to take medication on time with correct doses by December 20.
Objective 3
Increase patient participation in medication management by February 30.
Objective 4
Improve the transfer of medication information at transition from hospital to home by January 30.
Objective 5
(Enter your project objective description here)
PSLO1:
Apply organizational and systems leadership concepts to the management of human, fiscal, and physical health care resources for diverse populations in a variety of settings.
The objectives apply to organizational and system leadership concepts to manage staff through training and physical health care resources
PSLO2:
Evaluate processes, systems, and utilization of current technologies to support continuous quality improvement and promote safety in order to elevate patient outcomes in various settings across the care continuum.
The objective aligns with PSLO2. The current processes will evaluate the effectiveness and the utilization of the present technology to promote medication safety for quality improvement to evaluate patient outcomes.
PSLO3:
Synthesize scholarship from a variety of sources to promote the implementation of evidence-based practice.
The synthesized scholarship from various sources will be performed and used to implement evidence-based practice to improve medication safety. The synthesized scholarship from various sources will be performed and used to implement evidence-based practice to improve medication safety. The synthesized scholarship from various sources will be performed and used to implement evidence-based practice to improve medication safety.
PSLO4:
Evaluate healthcare policy, regulatory, legal, economic, ethical and sociocultural environments to advocate for patients and effect change in the healthcare system based on their role.
PSLO5:
Critique evidence-based delivery within an interdisciplinary team to serve diverse populations in a variety of local, national, and global settings.
Critiquing evidence-based delivery with interdisciplinary team to serve diverse populations in a variety of settings.
PSLO6:
Formulate a strategic plan and distinguish the key components required for success.
Strategic plan and distinguish the key components required for success Strategic plan and distinguish the key components required for success Strategic plan and distinguish the key components required for success Strategic plan and distinguish the key components required for success
PSLO7:
Analyze a budget and assure needed resources are planned for.
PSLO8:
Predict the needed resources (human and financial) to meet desired outcomes.
The needed resources to meet desired outcomes can be predicted The needed resources to meet desired outcomes can be predicted The needed resources to meet desired outcomes can be predicted The needed resources to meet desired outcomes can be predicted
PSLO9:
Implement change to meet desired quality measures.
The implementation of change for nursing staff to meet desired quality outcomes New medication scheduling tools to meet desired quality measures outcome
PSLO10:
Modify policies to meet external regulatory and accreditation standards.

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