Tele-pharmacists improving med reconciliation in LTC

WATERLOO, ONT. – The peopleCare Inc. group of nursing homes and retirement communities, in southern Ontario, is putting medication reconciliation back into the hands of the expert – the pharmacist.

In alliance with Hogan Pharmacy Partners Ltd, the organization has successfully transitioned from nurse-led paper reconciliation to pharmacist-led, digital reconciliation.

The move is giving nurses more time to spend on direct patient care and improving patient outcomes. It is also leading to far more efficient medication management, said Jenn Killing, Vice-President of Quality and Innovation at peopleCare.

“Hogan Pharmacy has really turned the medication model for long-term care completely on its head,” said Killing, noting that as many as seven out of 10 nurse-led paper-based reconciliations have errors or omissions. “Right away we were able to see huge benefits from e-prescribing,” she added.

A traditional nurse-led medication reconciliation process takes upwards of two hours to complete. Nurses need to find all sources of medication information for a resident – including medication administration records from hospitals or other facilities – and make recommendations about what drugs they should continue to take after admission.

“It can be a very complicated process, as residents may have a bag of pill bottles that needs to be documented as well,” explained Killing.

Once a medication list is compiled, the prescribing doctor signs it, but it can take months to “decipher what should happen or what should be taken off,” she added.

A pharmacy technician usually visits a home once or twice a month for consultation, but the process leaves substantial room for errors and discrepancies, an occurrence that’s estimated to be as high as 70 percent across Ontario.

In addition, compliance with Accreditation Canada Medication Standards is estimated to be just 57 percent using a nurse-led paper system.

Applying Hogan Pharmacy’s digital model, peopleCare staff notify the pharmacy that a new resident is arriving.

A pharmacy technician is on-site at each peopleCare home to compile the medication information, using new online tools to enter the list into a custom digital form in PointClickCare, the electronic medical record used by the majority of Ontario’s long-term care facilities.

Once the medication history is collected, the pharmacy technician shares the file with a remote telepharmacist – available 24 hours a day – who reviews the list for technical accuracy, accessing clinical information available in eHealth Ontario’s LTC eConnect system to conduct a thorough medication review.

“They look at it through a fully clinical lens to ensure the five rights of medication administration,” said Becky Agar, Vice President of Hogan Pharmacy. She added that pharmacists will consider things like, “Is a medication still appropriate for the resident? If they were hospitalized, were there medications started in hospital that shouldn’t be continued?”

The telepharmacist then contacts the prescribing physician to discuss the case and create the final admission medication order for the resident.

All information, including the original source documents for the medication list and the new medication order, is available in PointClickCare. That puts all relevant information for the resident in one place, enabling anyone on the multidisciplinary care-team with access to see it, explained Agar.

A paper copy is also printed for inclusion in a resident’s paper chart in order to comply with legislation.

“It was very important to make sure this was a pharmacy-led procedure because pharmacy practitioners are the medication experts,” said Agar. “There have been multiple studies in the acute care sector showing that pharmacist-led medication reconciliation has had better outcomes for a decade now.”

The team is now applying pharmacy expertise to the long-term care sector to obtain similar benefits for nursing-home residents.

One of the most notable advantages is that peopleCare nurses are now free to take arriving residents directly to their rooms, without stopping at a desk first to complete two hours of paperwork.

Medication reconciliation takes place “in the background,” explained Killing, and once a new medication order is created, PointClickCare sends a note to the entire care team to alert them.

“In our new process, the nurse can go to the room with the resident and start to care for them right away while assessing their other needs,” she said.

Following a successful pilot project in 2016, pharmacy-led digital medication reconciliation has been launched at all peopleCare homes, as well as a few other facilities supported by Hogan Pharmacy. Moving forward, the goal is to see the digital solution implemented at every long-term care facility in the province.

“Right away we could see the benefits to the residents and operational benefits to the home,” said Killing. “We realized it wasn’t enough for us to be saying this. We needed third-party research to support what we see happening every day in our homes.”

A year ago, peopleCare applied for and received financial support through the Office of the Chief Health Innovation Strategist and the Ontario Centres of Excellence Health Technologies Fund. The funding totalled $476,348 and is being used by an independent research team at the University of Windsor to evaluate nurse-led versus pharmacist-led reconciliation, as well as clinical outcomes for patients and operational benefits to the home.

Researchers are tracking 300 different data points as they review 70 nurse-led reconciliations and 70 pharmacy-led reconciliations across four long-term care facilities.

A portion of the funds will also be used to increase efficiency in the digital process by eliminating some of the data entry burden for pharmacy technicians. For example, the last step will be computerized physician order entry, allowing physicians to enter admission orders directly into the PointClickCare record from any digital device.

“Hogan has been supporting us with resources, but for this to truly meet the vision that every long-term care resident would receive this, it needs to be a sustainable, efficient process,” said Killing.

At the same time, residents and their family members remain a vital part of the medication reconciliation process, added Agar. “It’s very nice when we’re able to use the eConnect function to look at a hospital admission or download an Ontario Drug Benefit medication list, but you can never leave the resident or their caregivers out of the equation,” she said.

For example, a prescription record may instruct a resident to take one pill, twice daily, when they are actually taking two pills twice a day. It helps to have residents and families involved, to check on how patients are actually taking their meds.

“As much as we’re moving towards technology, we still try to remain very resident-centric because they’re an essential part of their own care,” said Agar.