Ambulatory Care Medrec Model

MedRec in Ambulatory Care

What is “Ambulatory Care”?

Ambulatory Care Services normally include a visit, encounter, consultation, treatment, and intervention using advanced technology, equipment or procedures. The patient’s stay at the facility, from the time of registration to discharge, occurs on the same calendar day.

Ambulatory care visits include medical/surgical outpatient/paediatric/follow-up clinics for patients that require:

Hospital visits of less than 3 hrs duration

Patients who are being seen by a variety of Specialists (i.e. fracture clinic, foot clinic, minor surgical and medical procedures, urgent medical clinic referrals, photo dynamic therapy, fluorescein angiography)

Ambulatory care day clinic treatment of longer than 3 hrs duration

Patients who require a degree of patient observation or recovery care ( i.e. Blood transfusion, Bone marrow, Kidney biopsy , IV infusions therapy)

Clinic services for admitted inpatients requiring expertise of the Ambulatory Care Staff . ( i.e. Bronchoscope, Application/ Removal of cast and traction, Paediatrics IV starts)

Reference: http://www.williamoslerhc.on.ca/body.cfm?id=178

Overview of Medication Reconciliation

What is Medication Reconciliation? Medication reconciliation is the formal process in which health care professionals partner with patients to ensure accurate and complete medication information transfer at interfaces of care. Medication reconciliation in ambulatory care involves using a systematic process to obtain a best possible medication history (BPMH) which reflects an accurate and complete list of all medications taken.

Who does the medication reconciliation? Assign the responsibility of medication reconciliation to a multidisciplinary team member. (i.e nurse, nurse practitioner, pharmacist, pharmacy technician, physician, healthcare practitioner). The person assigned the responsibility should have Best Possible Medication History (BPMH) training and use a systematic process to acquire the BPMH. The Medication Reconciliation Process in Ambulatory care

Screening criteria needs to be established by the organization. E.G. MedRat tool

Examples of screening criteria :

Patients:  On 7 or more medications  With 3 or more chronic conditions  On medications with a narrow therapeutic index (e.g. vancomycin, warfarin, aminoglycosides, phenytoin)  On high risk/alert medications (e.g. anticoagulants, insulin, opioids)  65 years of age or older and on 6 or more Prescribed Medications  With an Acute Care Admission since last clinic visit  Undergoing annual Medication Review  With an MD referral  With Chronic conditions – CHF, diabetes etc.

Examples of other criteria :  At transition points back to ambulatory care (i.e reconcile meds within 3 days of discharge from hospital and within 2 weeks of admission into the dialysis program.)  Frequency of reconciliation/clinic visit - e.g. every six months to every year depending on the patient  First Visit or Last visit greater than 6 months  any clinic where medications are changed  annual or semi-annual review

BPMH audits should be done periodically to ensure the quality of the medication reconciliation is maintained.

Partnering with the patient in helping them to be an active participant in keeping their medication record up-to-date and accurate is important. Asking patients to fill out their medication history prior to the clinic visit may be helpful.

Partnering and communicating with other ambulatory care clinics, hospitals, community pharmacies, home care, primary care physicians, specialists, long-term care providers and other care providers will help reduce ‘rework’ and improve the accuracy of the medication information gathered.

Utilizing innovative technologies in medication reconciliation will enable a continuous, efficient medication record that can be updated & accessed easily. Examples include: Google Health, TelusHealth, Microsoft Healthvault) universal open-sourced health records (“UHR”), USB flash drive medication record, ‘Knowledge is the best medicine’ modifiable pdf medical record, Pharmacy Access. These technologies could enable a faster, better & continuous medication review/reconciliation in the absence of a clinic-based electronic health record. The Medication Reconciliation Process in Ambulatory Care Clinics (Initial Visit) 1. Create the BPMH a. Gather information from sources of information

Possible information sources include:

. other ambulatory care clinic records (recent visits to ‘other’ ambulatory clinics’) . hospital discharge records . referral . prescription vials . community medication record (e.g. MedsCheck) . physician record . electronic provincial record (BC PharmaNet, ON - DPV, PEI - DIS, SK - PIP etc.) . hospital records . patient medication lists . patient /family interview . hospital Medication Administration Record.

b. Interview patient using a systematic process (e.g. BPMH interview guide) to establish the list of medications (including name of medication, drug route and frequency) the patient is actually taking. Medications include prescription, non-presciption, herbals, over the counter medications and medications taken on an as-needed basis (prns). c. Compare the information obtained from the patient interview with information gathered from other sources (other source information may be acquired prior to the clinic visit). d. Identify and document any discrepancies found between the sources of information and what the patient is actually taking, in the patient chart. (e.g. a paper/electric form may be useful) e. Resolve discrepancies at the clinic whenever possible and communicate irresolvable discrepancies to the next care provider for resolution. f. Document explicit actions taken and follow-up with the patient on the next visit. Document the BPMH in the patient chart.

If the discrepancy cannot be resolved Refer the patient to their family physician for resolution of the discrepancy.

4. Close the medication reconciliation loop by updating and communicating the reconciled medication list to the client at the end of the appointment.

Update the medication list with any changes made during the appointment.

Give a copy of the medication list to the patient and keep one on record in the patient chart.

Verify that the patient/caregiver understands any changes to their medication regimen.

Communicate the reconciled medication list to the other care providers as appropriate. (e.g. family physician, community pharmacist, family health team, homecare services etc.)

Remind the patient to: o Bring their medication list with them to every healthcare appointment, family physician/specialist, ER visit and to their community pharmacist. o Keep their medication list up-to-date whenever changes are made. o Carry their list with them at all times. The Medication Reconciliation Process In Ambulatory Care Clinics (Subsequent Visits)

1. Check for updates/changes to the medication list.

 Review the most recent medication list on record and the list/vials provided by patient.  Discuss any changes to the medication list with the patient by asking: o Are there any prescription medications you or your physician have recently stopped, changed , added or adjusted the dose? o What was the reason for the change? o Have you visited any other ambulatory clinics recently?  Update the medication list with the changes made since the last appointment

Goto Steps 2-4 of Initial Visit model