Introduction
Northwell Health Care System is a healthcare institution that provides health-related services to a consortium of at least 800 hospitals and care centers. Northwell Certified Home Health Agency (CHHA), a constituent of the Northwell Health Care System provides a range of professional home health services to its clientele. Medication errors are among the leading causes of morbidity and mortality during transitions from hospital to home care. These oversights hamper the smooth transition of patients from hospital to home settings and impact the performance of CHHA negatively. The purpose of this project was to improve medication safety and reconciliation in-home care settings post-discharge. Nurses were trained on the medication reconciliation process as well as the use of medication management time tools. The implementation of medication reconciliation by nurses was low. The reported rate of implementation was 12% instead of the targeted rate of 25%. The low rate of adoption of medication reconciliation was attributed to resistance and time constraints. However, the project led to the development of a medication management form that was incorporated into everyday practice. Furthermore, patients who received medication reconciliation services reported better outcomes in terms of few adverse drug events and lower rates of hospital readmission. It was recommended that CHHA should ensure adequate staffing to increase the likelihood of the adoption of evidence-based practice interventions and improve patient outcomes.
Background and Objectives
Organization
Northwell Health Care System is a healthcare organization that provides health-related services to a network of more than 800 hospitals and care centers. Northwell Certified Home Health Agency (CHHA) is part of the Northwell Health Care System whose role is to offer different home health services, for example, medical supplies, home health aides, occupational and speech therapists, medical and social services, in addition to nutritional services. Northwell Health Care System is devoted to the delivery of quality healthcare services to its customers in all spheres of operation. The organization accepts reimbursements for services rendered from Medicare, Medicaid, as well as private insurance companies. The mission of the organization is to improve the health and quality of life of the people and communities it serves through the provision of world-class service and patient-focused care.
Project Objectives
The overall goal of the project was to improve medication safety and reconciliation in-home care settings post-discharge. Four specific objectives were developed to achieve the overall goal. The first objective was 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 was to develop a medication schedule time tool that would increase the patients’ ability to take medications on time and in the right doses by the 20th of December. The third objective was to increase patient participation in medication management by the end of February. The fourth objective was to improve the transfer of medication information during the transition from hospital to home care by the 30th of January.
Reason for Project
The New York State Department is mandated to monitor the services rendered by CHHAs through quality measures, which are indications of how well home health agencies cater to their patients. HHCAHPS surveys, Medicare claims, and OASIS provide the data used in the development of quality measures. OASIS stipulated that federal evaluations should be done every time patients who were covered by Medicare or Medicaid were referred to home care, after 60 days of admission, and after discharge from the care provided by professional staff. Pharmacological intervention is the mainstay of treatment for most health conditions. The efficacy of this intervention is determined by correct drug use, which is in turn influenced by patients’ adherence to prescription instructions. The incorrect usage of medications 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. Therefore, this project strives to improve medication practices in home health settings as part of strategies to improve performance in terms of quality measures.
Issues and Documented Needs
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. 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).
As a home care nurse, it was noted that most patients encounter confusion regarding what medications to take at home following discharge from hospitals. 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 occurrences signify a gap in patients’ knowledge of medication use and the need for home care nurses to fill this void through appropriate interventions.
Expected Results
The expected outcome of the project was a 25% improvement in medication safety and reconciliation in-home care settings post-discharge. This outcome was expected to be achieved through the development of a medication schedule time tool aimed at promoting the correct usage of medications by patients. Other expected outcomes included increased patient involvement in medication management and enhanced transfer of medication data during hospital-home transitions.
Approach
Detail Scope of Project
The project covered components of medication-related care in home health settings. Precise aspects included training of nurses on medication reconciliation, implementation of the procedure on patients before discharge, and monitoring the effects of the intervention post-discharge. The project also looked at the medication management of patients by providing discharge instructions.
Implementation Plan and Its Component Parts
The first process in the project was stakeholder identification. Identifying stakeholders provided a clear understanding of the people who were going to be affected by the outcomes of the project directly and indirectly and allowed the researcher to provide periodic updates and feedback as required. The stakeholders for the project included home health nurses, patients, their families, and part of the Northwell Certified Home Health Agency administration. The stakeholders were then engaged to get their perceptions regarding the problem. Home health nurses were briefed about the issue of medication errors among patients and asked to explain some of the challenges they faced and what could be done to address them. Similarly, patients were asked to state some of the issues they faced when taking medications at home following discharge from the hospital. This information was helpful to customize the evidence-based interventions to match the precise needs of the stakeholders.
The second process was a literature search and evaluation. Evidence-based practice entails gathering, processing, and executing findings from research to improve clinical practice and patient outcomes (Skela‐Savič et al., 2017). Peer-reviewed articles were searched from databases such as PubMed, Google Scholar, and CINAHL using key search phrases such as medication reconciliation, home health care, and medication safety. The search was narrowed down to full-text articles published in the last five years. The abstracts were skimmed to identify relevant articles for subsequent use. A literature matrix table was used to summarize the key recommendations from the articles.
The third step was the collection of baseline data on medication errors, polypharmacy, and hospital readmissions associated with medication errors. These data were critical during the evaluation stage to determine the efficiency of the project. The fourth step involved training of staff members and the development of the medication schedule and time tool using information from the evidence-based research, whereas the fifth step was the implementation of the project, which entailed the actual use of the medication schedule time tool and medication reconciliation. The fifth step was data collection, which was followed by a final step of evaluation. Project evaluation denotes the methodical and objective appraisal of a continuing or completed project to determine the importance and extent of the attainment of project objectives, effectiveness, effect, and sustainability. Outcome evaluation was used to determine the effectiveness of the interventions and the attainment of project goals.
Method of Evaluation
Outcome evaluation provides data on project results and the extent to which those outcomes are attributed to the project. This form of evaluation also assesses the effectiveness of the project in achieving the expected results. The outcome evaluation was used in the appraisal of this project because it details project upshots and determines whether the initial goals were achieved or not. This form of evaluation would determine whether the project was successful or if further improvements were needed.
Results
Summary of Outcomes
Out of the total number of nurses who were trained on the medication reconciliation protocol, only 12% adhered to it in their subsequent encounters with patients. The intervention showed a substantial increase in patient self-management and knowledge of medication and safety. The proportion of patients who received the best practice of medication reconciliation showed a significant reduction in the potential readmissions after hospital discharge compared to the patient group that received usual care. For older patients who refilled their prescription medications after discharge from the hospital, completion of medication reconciliation processes and communication with the pharmacist was associated with a small decrease in deaths as well as low hospital readmission rates within 30 days of discharge. Findings from the literature search and appraisal led to the development of a medication schedule time tool, which was adapted for use as part of interventions during the transition of care.
Outcomes Analysis
The implementation of medication reconciliation by nurses as part of routine practice was 12%. The first project objective was to have a 25% increase in medication reconciliation by the end of the study. Therefore, the findings indicated that this objective was not attained. However, the adoption of the medication management time tool, which was referred to as the “medication sheet” in simple terms, was 100%. The second objective was to develop a medication schedule time tool that would increase the patients’ ability to take medications on time and in the right doses by the 20th of December. In contrast, the fourth objective was to improve the transfer of medication information during the transition from hospital to home care by the 30th of January. The successful development and acceptance of the medication sheet implied that the second and fourth objectives were achieved. The third objective was to increase patient participation in medication management by the end of February. Reductions in mortality and readmission rates following increased patient interactions with the pharmacist during the medication reconciliation process signified increased patient involvement in medication management. Nonetheless, it was not possible to track the precise extent to which this goal was attained.
Discussion
Lessons Learned
One notable observation was the low adoption of medication reconciliation by nurses as part of routine care, which implied that system inefficiencies have a negative impact on the acceptance and success of evidence-based interventions (Pas et al., 2020). The inability to determine the extent of patient involvement in the medication management process indicated a flaw in part of the methodology. Furthermore, it was noted that changing patients’ attitudes towards medication was the key to their increased positive involvement in medication management. It had been anticipated that client habits would pose a challenge to the project by disregarding specialists’ recommendations and depending on their perceived knowledge of medications. The overall duration of the project was inadequate to realize the outcomes of the intervention fully. Such quality improvement projects should be planned with more time to permit the researcher to observe a true reflection of the impact of the intervention.
Interpretation
The low rates of nurses following the medication reconciliation protocol (12%) in the study suggest that there may be challenges with the current implementation of the program. Additionally, low rates of nurses embracing the medication reconciliation process suggest resistance to change. Resistance is a common occurrence in most change initiatives because new procedures disturb the status quo and require adjustments (Shahbaz et al., 2019). A possible explanation for the reluctance is that the nurses were faced with large workloads, which resulted in time constraints and limited time to complete the best practice of medication reconciliation.
It was noted that late or the lack of medication reconciliation after discharge was associated with increased physician and emergency department visits but no reduction in the rates of readmission. Medication reconciliation by nurses is more effective at preventing adverse medication events. However, delayed medication reconciliation increased the incidence of adverse drug events, leading to increased hospital visits (Liu et al., 2019). In contrast, late-presenting patients may be sicker and more likely to experience negative outcomes regardless of medication reconciliation efforts. A newly developed medication sheet was included as a component of transitional care interventions, which led to reductions in readmission rates. This observation corroborated findings by Grigg et al. (2017) where an anesthesia medication template led to a reduction in medication errors in the course of anesthesia.
Recommendation
To address the issue of clients’ habits, future studies should look into interventions to promote positive changes in the medication practices of patients. The low rates of implementation of medication reconciliation were attributed to increased workloads and time constraints among nurses. Therefore, CHHA needs to ensure that the organization has adequate personnel and efficient technology as well as logistics to leave nurses with ample time to achieve these goals.
Conclusion
The findings of this study indicate that medication reconciliation enhances patient safety and reduces the rates of hospital readmissions. Additionally, patient engagement with clinicians before discharge increases the efficiency of medication management reduces adverse drug events and lowers the rates of mortalities and hospital readmissions. However, low rates of medication reconciliation by nurses can be attributed to system inefficiencies such as understaffing, which leaves nurses with heavy workloads and reluctance to embrace new interventions meant to enhance the quality of care. Furthermore, addressing clients’ attitudes was essential to ensure compliance with professional advice on medication use. Therefore, clinical settings, including CHHAs should address these inefficiencies to increase the acceptance of beneficial quality improvement interventions such as medication reconciliation.
References
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. Web.
Grigg, E. B., Martin, L. D., Ross, F. J., Roesler, A., Rampersad, S. E., Haberkern, C., Low, D.K., Carlin, K., & Martin, L. D. (2017). Assessing the impact of the anesthesia medication template on medication errors during anesthesia: A prospective study. Anesthesia & Analgesia, 124(5), 1617-1625. Web.
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. Web.
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 settings during care transition from hospital to primary care. Journal of Family Medicine and Primary Care, 7(3), 501-506. Web.
Liu, V. C., Mohammad, I., Deol, B. B., Balarezo, A., Deng, L., & Garwood, C. L. (2019). Post-discharge medication reconciliation: Reduction in readmissions in a geriatric primary care clinic. Journal of Aging and Health, 31(10), 1790-1805. Web.
Mickelson, R. S., & Holden, R. J. (2018). Medication adherence: Staying within the boundaries of safety. Ergonomics, 61(1), 82-103. Web.
Pas, E. T., Johnson, S. L., Alfonso, Y. N., & Bradshaw, C. P. (2020). Tracking time and resources associated with systems change and the adoption of evidence-based programs: The “hidden costs” of school-based coaching. Administration and Policy in Mental Health and Mental Health Services Research, 47(5), 720-734. Web.
Shahbaz, M., Gao, C., Zhai, L., Shahzad, F., & Hu, Y. (2019). Investigating the adoption of big data analytics in healthcare: The moderating role of resistance to change. Journal of Big Data, 6(1), 1-20.
Skela‐Savič, B., Hvalič‐Touzery, S., & Pesjak, K. (2017). Professional values and competencies as explanatory factors for the use of the 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. Web.