The E3 Learning Collaborative, sponsored by Cardinal Health Foundation and coordinated by the Alliance for Integrated Medication Management (AIMM), includes 13 grant recipients who have committed to implementing or scaling programs with a focus on value-based care delivery, improving medication safety across care transitions for high-risk populations.[1] The teams include conveners, hospitals and health systems, and community providers. One theme that surfaced during the first year of the collaborative has been challenges and considerations related to medication reconciliation. Medication reconciliation has been in the forefront of patient safety efforts in hospitals and health-system since the early 2000’s. Medication-related discrepancies at hospital admission have been identified in more than half of patients, and contributed to treatment delays, readmissions, and adverse events.[2] In 2005, the Joint Commission energized the issue when it added medication reconciliation as a Patient Safety Goal, to be assessed at all organizations seeking accreditation. As of July 2011, medication reconciliation has been incorporated into National Patient Safety Goal #3, “Improving the safety of using medications,” and requires that organizations “maintain and communicate accurate medication information” and “compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital in order to identify and resolve discrepancies.”[3]

“Transitions in care include changes in setting, service, practitioner or level of care”-The Joint Commission
“….obtain and maintain accurate and complete medication information for a patient and use this information within and across the continuum of care to ensure safe and effective medication use.”- ASHP/APhA[4]

Little has been published about challenges with medication reconciliation in the community setting or conversations with stakeholders beyond the acute care setting. It was clear that the community setting and transitions across “downstream” providers offer unique opportunities and challenges to conducting medication reconciliation. As the collaborative began to share their challenges, it was discovered that there was not a common definition of the core elements of medication reconciliation. While it begins with a complete medication history; there is also a requirement beyond documenting the medication list, a responsibility to clarify any medication-related concerns that are identified. The Collaborative members agreed with the consensus of the 2012 report, Improving Care Transitions: Optimizing Medication Reconciliation, that this information must be “used within and across the continuum of care to ensure safe and effective medication use.”[4]  Figure 1 reflects the expanded care transition spectrum where medication reconciliation should be routinely conducted for high risk patients.

Historically, the focus on medication reconciliation has been for transitions to and from acute care settings.

After their first full year of implementation, the E3 Collaborative participants identified that improving medication reconciliation is a significant opportunity to improve the success of their care transition programs and thus, improve patient care. They also identified several considerations that need to be addressed when implementing care transition programs (Figure 2). These considerations fall into four main categories: issues unique to medically complex patients, most with chronic illness; social determinants of health; care coordination; and person and family engagement. As organizations and payers move toward value-based payment reforms and population health management, the perspective on medication reconciliation needs to become more patient-centric and expand its reach into the community and home.

Figure 2. Key Considerations for Medication Reconciliation Identified by the E3 Collaborative

Medication reconciliation processes should be implemented across care transitions and applicable to all settings. These processes should support a “culture of collaboration” that extends to downstream organizations (e.g. nursing homes and home health organizations) as well as individual providers (nurses, pharmacists in the community, and physicians). Such collaborations will ensure timely and responsive access to information and support provider conversations to resolve any issues identified; and by extension, optimize population health outcomes and value-based care delivery. It is important to develop medication reconciliation processes that are patient-centric and that address these considerations identified by the E3 Learning Collaborative.

Toni Fera, BS, PharmD
AIMM Management Team

[4] Improving care transitions: Optimizing medication reconciliation. American Pharmacists Association and American Society of Health-System Pharmacists, Journal of the American Pharmacists Association , Volume 52 , Issue 4 , e43 – e52