Adopting medication reconciliation and seamless care services
Dr. Neil J. MacKinnon, College of Pharmacy, Dalhousie University
Medication reconciliation and seamless care services can dramatically reduce adverse outcomes resulting from gaps in the medication use system. A long-running initiative to promote these services as standard care was sparked by innovative hospital and community pharmacists, and subsequently taken up by two national pharmacy associations. A series of wide-ranging knowledge translation (KT) activities, including a joint task force on seamless care, national and regional workshops and the publication and dissemination of educational materials, has resulted in these services transitioning from isolated pilot projects to the focus of national patient safety efforts in less than 10 years.
As patients transition across the health care system, gaps in medication use between physical environments, such as hospitals and community pharmacies, can adversely affect health outcomes. The provision of medication reconciliation and seamless care services can dramatically reduce adverse outcomes such as drug-related problems, inconsistencies, and omissions.1
Seamless care is "the desirable continuity of care delivered to a patient in the health care system across the spectrum of caregivers and their environments."2 Medication reconciliation, one component of seamless pharmaceutical care, ensures the collection and communication of accurate patient medication information, with a goal to facilitate continuity of pharmaceutical care for patients at the beginning and/or the end of service.3 These activities typically involve having a health professional, usually a clinical pharmacist, review the patient's medication profile prior to discharge to ensure the patient is taking the correct medications, doing a full pharmaceutical care work-up and communicating relevant information to the next care provider.
This KT initiative consisted of understanding and addressing gaps in the medication use system through the implementation of medication reconciliation and seamless care services. The goal was to move medication reconciliation and seamless care from infrequently provided services to a recognized standard of care. The audiences for this research include health care executives and administrators, health professionals, health care regulatory agencies, and others involved in improving the safety and effectiveness of the medication use system.
The KT initiative
A wide variety of partners participated (and continue to participate) in this initiative. In the mid- to late 1990s, innovative hospital and community pharmacists across Canada conducted several independent pilot projects aimed at determining the feasibility of medication reconciliation and seamless care services. Sensing the need for coordination of activities in this area, the Canadian Society of Hospital Pharmacists (CSHP) and the Canadian Pharmacists Association (CPhA) formed a joint task force on seamless care and co-hosted a national workshop in 1998 in Ontario. The aims of the workshop included increasing awareness of the experience of providing seamless care and identifying mechanisms to move the seamless care effort forward.2 A second workshop was held in Quebec in 2000 to share and develop tools to assist in the delivery of seamless care.4 Several regional workshops followed to share more success stories and to train other community and hospital pharmacists. A randomized, controlled trial consisting of 253 patients testing these services was conducted over 2000-2002 at The Moncton Hospital in New Brunswick.1 In this study, pharmacist-directed seamless care services were found to have a significant impact on drug-related clinical outcomes and processes of care.
Learnings from these studies for others wishing to implement these services were incorporated into a "how-to" book—Seamless Care: A Pharmacist's Guide to Providing Continuous Care Programs5—that was published by CPhA in 2003. A particular effort was made to ensure uptake of the book by the educational community by obtaining sponsorship for its purchase for all the attendees of the Canadian Association of Pharmacy Students and Interns 2003 Professional Development Week (approximately 550 students). Copies of the book were also provided to the deans of Canada's nine faculties of pharmacy, and faculty at the 2003 Canadian Pharmacy Administration Teachers' Conference.
Results of the KT initiative
In less than 10 years, these services have progressed from being evaluated in pilot studies to now being the focus of national patient safety efforts.
This multi-pronged KT approach has had a substantial impact on the adoption of medication reconciliation and seamless care services across Canada. In less than 10 years, these services have progressed from being evaluated in pilot studies to now being the focus of national patient safety efforts.
In 2004, CSHP released an official statement supporting the implementation and provision of seamless care services.6 Further evaluation of pharmacist-directed seamless care services is presently occurring with a new randomized, controlled study involving cancer patients in Newfoundland and Labrador. Recently, much activity has focused on medication reconciliation, a subset of seamless pharmaceutical care. The reason for this shift remains unclear but may, in part, be due to the promotion of medication reconciliation in the United States. Medication reconciliation services have been adopted in the 2005 Canadian Council on Health Services Accreditation (CCHSA) patient safety goals, and in the Safer Healthcare Now! campaign of the Canadian Patient Safety Institute (CPSI). These two initiatives will go a long way toward moving medication reconciliation and seamless care into an accepted standard of practice. Hopefully, institutions or organizations that adopt medication reconciliation practices will use them as stepping stones to the full implementation of comprehensive seamless pharmaceutical care.
The adoption of these services beyond just the pilot sites and the initial participating pharmacists has been one of the most satisfying aspects of this KT initiative.
Still, there is much work to be done. While adoption of these services has generally occurred at the hospital to community transition point, much effort will be required to eliminate other gaps, such as those from the community to hospital, hospital to long-term care facilities, and even at transition points within hospitals. The inclusion of medication reconciliation services in the CCHSA patient safety goals provides a powerful incentive for all hospitals to provide these services, but also creates challenges for hospital pharmacy directors and others involved in implementation, given the current shortage of hospital pharmacists and budgetary restraints. Training programs, such as those recently sponsored by the CPSI in Alberta in May 2005, should help overcome some of the implementation barriers. There will also be operational and workload considerations for community pharmacists; at this time, these have not been adequately addressed.
One positive change is that these services are no longer being promoted primarily by the pharmacy profession. Indeed, health care executives and other health professionals, such as physicians, nurses, and risk managers, are now increasingly involved in their uptake. This provides further evidence of the success of this KT initiative—it is no longer a discipline- or profession-specific activity, but instead is a valued service recognized by health care decision makers, clinicians, and ultimately by patients, who experience it first-hand. The adoption of these services beyond just the pilot sites and the initial participating pharmacists has been one of the most satisfying aspects of this KT initiative.
Looking back, what were the keys to success for this KT initiative? Several are apparent, and include:
- The uptake of seamless care and medication reconciliation by front line pharmacists who believed in these concepts and were able to convince others of their value;
- The cooperation of hospital and community pharmacists at the local, provincial, and national levels;
- Engagement of the pharmacy practice research community, so evidence of the value of these services could be obtained;
- A proactive effort to shift participation from the idea champions and change leaders to others through the use of national and regional workshops; and
- Training future pharmacists on these services.
No KT initiative occurs in isolation and credit must also be given to external events that influenced our activities.
Hepler and Strand's articulation of pharmaceutical care as the practice model for the pharmacy profession in the late 1980s and early 1990s did much to pave the way for increased responsibilities for pharmacists in all practice settings.7 More recently, the awareness of patient safety issues, in both those working in the health care system and in the general public, has risen considerably. In the past five years, the publication of several sentinel reports in Canada and the United States, and the creation of the CPSI, has done much to increase our knowledge about the magnitude of preventable drug-related morbidity, medication errors, and other adverse outcomes of medication use. The CPSI has also stimulated the search for tools and techniques to improve the safety of the medication use system.
Despite these successes, there are still several goals related to seamless care and medication reconciliation that have yet to be achieved. At this time, there are few published evaluations of these services in the peer-reviewed literature. The National Association of Pharmacy Regulatory Authorities or the provincial regulatory bodies have yet to mandate the provision of these services, and reimbursement or compensation for those providing such services is still lacking. Additionally, technology such as linked prescription profiles and health cards could potentially play a large role in facilitating these services, but at this time remain underutilized.
Conclusions and implications
It provides a tangible example of how a simple, yet essential, element of the health care system can move from the exception to the norm in a relatively short period of time.
This initiative was an effective model for combining the efforts of national professional associations, practitioners, and researchers. For the pharmacy profession, it provides a powerful example of taking one small aspect of the medication use system and ensuring that it is widely adopted. For those outside the pharmacy profession, it provides a tangible example of how a simple, yet essential, element of the health care system can move from the exception to the norm in a relatively short period of time, through the partnership of front line health professionals, health care management, professional associations and researchers.
1 Nickerson, A., N. J. MacKinnon, N. Roberts, and L. Saulnier. Forthcoming. Drug-therapy problems, inconsistencies and omissions identified during a medication reconciliation and seamless care service. Healthc Q.
2 Canadian Society of Hospital Pharmacists and Canadian Pharmacists Association. 1998. Proceedings of the Seamless Care Workshop. Ottawa, ON: Canadian Society of Hospital Pharmacists and Canadian Pharmacists Association.
3 Canadian Council on Health Services Accreditation. 2005. CCHSA Patient/Client Safety Goals & Required Organizational Practices. Frequently Asked Questions—Updated June 6, 2005.
4 Canadian Society of Hospital Pharmacists and Canadian Pharmacists Association. 2001. Seamless Care Workshop: Highlights. Ottawa, ON: Canadian Society of Hospital Pharmacists and Canadian Pharmacists Association.
5 MacKinnon, N. J., ed. 2003. Seamless Care: A Pharmacist's Guide to Providing Continuous Care Programs. Ottawa, ON: Canadian Pharmacists Association.
6 Canadian Society of Hospital Pharmacists. 2004. Statement on Seamless Care. Ottawa, ON: Canadian Society of Hospital Pharmacists.
7 Hepler, C. D., and L. M. Strand. 1990. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 47 (3): 533-43.
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