Tim Gieseke, MD, CMD

In the previous WAVE, a plea was made for better post acute care transitions from the nursing home to RCFE or Home settings.  The emphasis was on the comprehensive discharge summary as means to communicate to subsequent providers information that supports seamless continuity of care.  One of our esteemed members, Dr. Rebecca Ferrini, recognized gaps in the “Medication Reconciliation” part of the discharge summary. 

This is one of the 4 “Pillars” of Eric Coleman’s care transitions model and is a requirement for all acute care hospitals, because the evidence shows this prevent serious medication errors. 

Can we do better?  I have attached a template spreadsheet (Current SNF Med List) used in some of my facilities.  In its current format, it is completed by nursing and social services on the basis of the patient’s current SNF meds.  The meds are typed into the list with the identified indication from our MAR.  This is sent to the attending physician for their modification and signature.  This document is then given to the patient as well as faxed to their pharmacy, and identified outpatient physicians.

In this model, since medication reconciliation with the former medicines has not occurred, we need to inform our patients (families) not to take their different home medicines, but instead bring those medicines in with them to their first appointment with their PCP (ideally within 1 week of discharge).  Medications that will no longer be taken should be destroyed so they are not a future source of confusion or harm.

Can we do better?  In partnership with one of my facilities, we have modified our discharge process to support medication reconciliation.

1. As a part of our admission process, we will be working with our referral hospitals for consistent access to their pre-hospital medication list and will verify it’s accuracy with the patient, family, and possibly outpatient pharmacies.
2. We have modified our current discharge tools to provide our patients and outpatient physicians with a clear list of “Discharge Meds” (what to take, what to stop, and what to do with meds not identified, and meds which will not be used in the future).
3. Attached is a Pre-Hospital Medication List spread sheet, to document the information obtained during the admission process.
4. Attached is the Current SNF Meds List that nursing currently prepares prior to discharging a patient home.
5. Attached is the Discharge Notification and Order Request Form we have modified which provides discharge order details and instructs our attendings to complete both Pre-Hospital and Current SNF Med list Forms.  All 3 forms are then faxed back to us.
6. We then use this information to create the final Discharge Med List (attached spread sheet) given to our patients and faxed to their physicians.

I realize this process is not yet tested, but I believe it’s a step in the right direction.  You are welcome to test and modify these tools.

At CALTCM, we are committed to improving the discharge “Hand-Off” and hope you will take up the challenge, “Can we do better”?

Access the sample forms and templates mentioned in this article by clicking here.