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Overview

Updated on October 30, 2014

“Right now we spend a lot of time trying to diagnose what is wrong with the patient, yet often miss the fact that there is a medication-related problem. This means that patients often go home still on a medication which may be causing harm.”
Dr. Corinne Hohl, Associate Professor, Faculty of Emergency Medicine – University of British Columbia

The material for Medications Management was developed in collaboration with Institute for Safe Medication Practices Canada, led by Lisa Sever.

Issue:

Medication management strives to ensure that each client’s medications are assessed as appropriate, effective for the specific medical condition, safe considering all of the client’s other conditions and medications, and that the client is able to take the medication as intended. In a home care setting, doctors, nurses, pharmacists, personal support workers, family caregivers, and clients all work together to achieve effective medication management.1

Components of a medication management protocol include1:

  • Assessment of a client’s medication-related needs
  • Identification of medication-related problems
  • Development of a personalized care plan for each client
  • Follow-up by providers to evaluate client health outcomes


Adverse drug events are costly to the health care system, requiring greater use of health services.2 People are admitted to emergency departments because of adverse drug events related to side effects, non-adherence, and wrong or suboptimal drug therapy. In 2007, the total measured costs of adverse drug event related emergency department visits and subsequent hospitalizations in seniors was estimated to cost $13.6 million in Ontario. In addition, it was found that patients with severe adverse drug reactions had emergency department costs that were nearly three times more than patients with mild reactions.3

More than half of home care clients in Ontario in 2012-2013 were referred from hospital.4 Hospital to home transition is a particularly problematic area for medications, with studies showing discrepant medication regimens in 41% to 95% of clients once home.5-7

Decisions about medications are often made by clients and their caregivers that may put the client’s health at risk.8 The average age of long-stay home care clients in Ontario in 2013-14 was 80 years and the top three disease states among these clients are hypertension (61%), arthritis (52%) and diabetes (27%).4 These diseases are typically associated with a heavy drug burden of medications (e.g. insulin, oral hypoglycemic, opioids).9,10 Psychotropic drugs which affect mental activity, behaviour, or perception are known to cause falls. The data shows that 86% of clients are taking at least one psychotropic drug.4,11 Polypharmacy (i.e., taking five or more medications) has been identified as one of the strongest factors associated with adverse events – increasing the odds of experiencing an adverse event by 20%.8

The good news is accreditation bodies such as Accreditation Canada are recognizing the importance of medication safety across the home care continuum. Accreditation Canada has updated their standards Medication Management Standards for Community Based Organizations.12 Once home, medications need to be continually monitored to prevent adverse events.

Call to Action:

Recent reviews have illustrated the significance of medication use in the home care setting.13-15 Canadian Patient Safety Institute released Safety at Home: A Pan-Canadian Home Care Safety Study, which showed medication related incidents resulting in an emergency department visit or hospitalization was one of the most frequent adverse events.

Safe and standardized procedures for medication handling (i.e., prescribing, procuring, dispensing, administering, disposing, storing and monitoring) in the home care environment is critical. Clients also need medication regimens that are safe, effective and manageable. Implementing evidence-based practice will help clients use medications safely at home. Identifying clients at risk from their medication use or lack thereof will ensure they are not at risk for medication safety issues. Nurses, personal support workers, and family caregivers play important roles in identifying medication safety issues and preventing adverse events.

Pharmacists play a pivotal role in preventing and resolving medication related problems. Four of the fourteen Community Care Access Centres (CCACs) in Ontario have staff or contracted pharmacists as part of their home visiting teams to improve client safety.16 Community pharmacists can perform a MedsCheck at home, visit annually to review all prescription and non-prescription medications, help remove expired and discontinued medications, and monitor medication taking behaviours.17 There is also some emerging evidence that comprehensive medication reviews performed by home care pharmacists can improve safety (e.g., reduce falls).18,19 To ease the transition home from the hospital, the Ministry of Health and Long-Term Care has funded the Rapid Response Nursing program across the province to perform medication reconciliation within 24-hours of discharge from hospital and resolve medication discrepancies in a timely manner.20

Standardized medication management programs for home care clients are in their infancy in Ontario – and even across Canada. Some practice areas are well defined by evidence such as a collaborative team approach, medication reconciliation, comprehensive medication review by pharmacists, and nursing medication administration standards. Other areas that need further development, include:

  • Understanding and supporting the needs of clients and caregivers
  • Managing the medication list
  • Identifying clients at risk using a standardized assessment tool
  • Incorporating pharmacists into the home care funding model
  • Improving links between primary care and home care
  • Educating home care providers and family caregivers who administer medications
  • Ensuring all medication issues are communicated among clients, caregivers, and all home care and health care providers


This quality improvement resource provides evidence-based best practices for improving medication management in home care settings and can lead you on a path toward providing home care clients with the best possible care, especially where standard medications management protocols are not available or applied.

  1. Rogers E. The patient-centred medical home and medication management. Journal for Patient Compliance.

    2011;1(1):20-3.
    Available from: http://issuu.com/mark123/docs/jpc-volume1-issue1?e=1460915/2907264

  2. Hohl CM, Nosyk B, Kuramoto L, Zed PJ, Brubacher JR, Abu-Laban RB, et al. Outcomes of emergency department patients presenting with adverse drug events.

    Annals of emergency medicine. 2011;58(3):270-9.e4.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/21354651

  3. Wu C, Bell CM, Wodchis WP. Incidence and economic burden of adverse drug reactions among elderly patients in Ontario emergency departments: a retrospective study.

    Drug safety: an international journal of medical toxicology and drug experience. 2012;35(9):769-81.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/?term=Incidence+and+economic+burden+of+adverse+drug+reactions+among+elderly+patients+in+Ontario+emergency+departments%3A+a+retrospective+study

  4. Canadian Institute for Health Information. Home Care Reporting System Profile of Clients in Home Care 2013-2014.

    Ottawa: Canadian Institute for Health Information, 2014.
    Available from: http://www.cihi.ca/CIHI-ext-portal/internet/EN/Quick_Stats/quick+stats/quick_stats_main?xTopic=Community%20Care&pageNumber=1&resultCount=10&filterTypeBy=undefined&filterTopicBy=2&autorefresh=1

  5. Wong JD, Bajcar JM, Wong GG, Alibhai SM, Huh JH, Cesta A, et al. Medication reconciliation at hospital discharge: evaluating discrepancies.

    The Annals of Pharmacotherapy. 2008;42(10):1373-9.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/18780806

  6. Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge.

    Quality and Safety in Health Care. 2006;15(2):122-6.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/?term=Reconcilable+differences%3A+correcting+medication+errors+at+hospital+admission+and+discharge

  7. Mulhem E, Lick D, Varughese J, Barton E, Ripley T, Haveman J. Adherence to medications after hospital discharge in the elderly.

    International journal of family medicine. 2013;2013:1-6.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/23589775

  8. Canadian Patient Safety Institute, The Change Foundation, Canadian Foundation for Healthcare Improvement.

    Safety at home. A pan-Canadian home care safety study. 2013.
    Available from: http://www.patientsafetyinstitute.ca/english/research/commissionedresearch/safetyathome/documents/safety%20at%20home%20care.pdf

  9. Hypertension CANADA. Hypertension without compelling indicators 2014.

    [cited 2014 August 14].
    Available from: https://www.hypertension.ca/en/professional/chep/therapy/hypertension-without-compelling-indications

  10. Cheng AY. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada.

    Introduction. Canadian Journal of Diabetes. 2013;37.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/24070926

  11. Hill K, Wee R. Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem.

    Drugs & Aging. 2012;29(1):15-30.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/?term=Psychotropic+drug-induced+falls+in+older+people%3A+a+review+of+interventions+aimed+at+reducing+the+problem

  12. Accreditation Canada. Qmentum Program. Standards.

    Medication Management Standards for Community-Based Organizations: Accreditation Canada; 2014.
    Available from: http://www.accreditation.ca/medication-management-standards

  13. Masotti P, McColl MA, Green M. Adverse events experienced by homecare patients: a scoping review of the literature.

    International Journal for Quality in Health Care. 2010;22(2):115-25
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/?term=Adverse+events+experienced+by+homecare+patients%3A+a+scoping+review+of+the+literature

  14. Macdonald M, Lang A, Storch J, Stevenson L, Donaldson S, Barber T, et al. Home care safety markers: a scoping review.

    Home health care services quarterly. 2013;32(2):126-48.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/23679662

  15. Godfrey CM, Harrison MB, Lang A, Macdonald M, Leung T, Swab M. Homecare safety and medication management with older adults: a scoping review of the quantitative and qualitative evidence.

    The Joanna Briggs Institute of Systematic Reviews and Implementation. 2013;11(7).
    Available from: http://joannabriggslibrary.org/index.php/jbisrir/article/view/959

  16. Institute for Safe Medication Practices Canada. Environmental Scan Medication Safety in Home Care.

    Pending publication: Institute for Safe Medication Practices Canada; 2014 [updated June].

  17. Ontario Ministry of Health and Long-Term Care.

    MedsCheck at Home [August 22, 2014].
    Available from: http://www.health.gov.on.ca/en/pro/programs/drugs/medscheck/docs/home.pdf

  18. Canadian Patient Safety Institute, Institute for Safe Medication Practices Canada.

    MedRec in the Home Care Setting: Sharing Ontario's Central Community Care and Access Centre's Success Story. 2012.
    Available from: http://www.saferhealthcarenow.ca/EN/events/NationalCalls/2012/Pages/Sharing-Ontario%E2%80%99s-Central-Community-Care-and-Access-Centre%E2%80%99s-Success-Story.aspx

  19. Reidt SL, Larson TA, Hadsall RS, Uden DL, Blade MA, Branstad R. Integrating a pharmacist into a home healthcare agency care model: impact on hospitalizations and emergency visits.

    Home healthcare nurse. 2014;32(3):146-52.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/?term=Integrating+a+pharmacist+into+a+home+healthcare+agency+care+model+and+qualitative+evidence

  20. Ministry of Health and Long-Term Care Ontario.

    Ontario expanding nursing care 2012 [updated May 10].
    Available from: http://news.ontario.ca/mohltc/en/2012/05/ontario-expanding-nursing-care.html

Best Practices

Updated on October 30, 2014

Evidence-informed best practices are based on quality evidence and should be implemented into practice to optimize outcomes. Listed below you will find best practices graded according to the level of evidence. To view a description of the levels of evidence, click here.

Change ideas are specific and practical changes informed by experience and research that focus on improving specific aspects of a system, process or behaviour. To learn more about change ideas see the QI: Getting Started tab.

Medication management is complex. Recent scoping reviews indicate that home health care professionals need to work together, increase communication and knowledge to address medication issues.1, 2 Polypharmacy, non-adherence, lack of monitoring and side effects contribute to unsafe situations.3-6 Evidence shows that pharmacists trained to do comprehensive medication reviews can lead to positive outcomes.6 There are also suggestions to engage and educate clients and caregivers and to improve the skills and assessment capabilities of home health professionals.2,7

Listed below are best practices to reduce and prevent falls and related injuries. These are based on literature reviews of evidence for each practice. To help you move from best evidence to best practice, click on the + button next to each best practice to find implementation details, as well as change ideas that you can test using a PDSA approach.

For each best practice, indicators to measure these practices are noted by the indicator number they are referred to on the measurement page.

  1. Canadian Patient Safety Institute, The Change Foundation, Canadian Foundation for Healthcare Improvement.

    Safety at home. A pan-Canadian home care safety study. 2013.
    Available from: http://www.patientsafetyinstitute.ca/English/research/commissionedResearch/SafetyatHome/Pages/default.aspx

  2. Masotti P, McColl MA, Green M. Adverse events experienced by homecare patients: a scoping review of the literature.

    International Journal for Quality in Health Care. 2010;22(2):115-25.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/?term=Adverse+events+experienced+by+homecare+patients%3A+a+scoping+review+of+the+literature

  3. Doran DM, Hirdes J, Blais R, Baker RG, Pickard J, Jantzi M. The nature of safety problems among Canadian homecare clients: evidence from the RAI-HC© reporting system.

    Journal of Nursing Management. 2009;17(2):165-74.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/?term=The+nature+of+safety+problems+among+Canadian+homecare+clients%3A+evidence+from+the+RAI-HC%C2%A9+reporting+system

  4. Hohl CM, Nosyk B, Kuramoto L, Zed PJ, Brubacher JR, Abu-Laban RB, et al. Outcomes of emergency department patients presenting with adverse drug events.

    Annals of Emergency Medicine. 2011;58(3):270-9.e4. Epub 2011/03/01.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/21354651

  5. Wu C, Bell CM, Wodchis WP. Incidence and economic burden of adverse drug reactions among elderly patients in Ontario emergency departments: a retrospective study.

    Drug safety: An International Journal of Medical Toxicology and Drug Experience. 2012;35(9):769-81.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/?term=Incidence+and+economic+burden+of+adverse+drug+reactions+among+elderly+patients+in+Ontario+emergency+departments%3A+a+retrospective+study

  6. Godfrey CM, Harrison MB, Lang A, Macdonald M, Leung T, Swab M. Homecare safety and medication management with older adults: a scoping review of the quantitative and qualitative evidence.

    The Joanna Briggs Institute of Systematic Reviews and Implementation. 2013;11(7).
    Available from: http://www.joannabriggslibrary.org/jbilibrary/index.php/jbisrir/article/view/959

  7. Sears N, Baker GR, Barnsley J, Shortt S. The incidence of adverse events among home care patients.

    International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care. 2013;25(1):16-28.
    Available from: http://www.ncbi.nlm.nih.gov/pubmed/23283731

Measurement

Updated on October 30, 2014

How will we know if a change is an improvement? Measurement is one of the critical steps in a quality improvement (QI) initiative that assesses the impact of your tests of change. Quality indicators are used to measure how well something is performing. There are three types of quality indicators used to measure your QI efforts: outcome (indicators that capture clinical outcomes and or system performance), process (indicators that track the processes that measure whether the system is working as planned), and balancing indicators (indicators that ensure that changing one part of the system does not cause new problems in other parts of the system).

Type of Indicator Indicator of Quality Improvement How to Calculate:

numerator
__________

denominator
Targets/ Benchmarks
Process Percentage of staff* trained on MedRec1 process
*Staff includes anyone who performs MedRec (e.g., nurses, care coordinators, pharmacists, pharmacy technicians)

Indicator number: i1
Number of staff* trained on MedRec process
Total number of staff
Targets are set by CCACs & individual providers

Provincial benchmarks are not available
Transition Processes Percentage of clients who have had MedRec completed when admitted to home care from hospital

Indicator number: i2
Number of clients who had MedRec on admission to home care from hospital
Total number of clients admitted from hospital
Percentage of clients who have had MedRec completed upon admission to home care from community

Indicator number: i3
Number of clients with completed MedRec on admission to home care from community
Total number of clients admitted to home care from community
Percentage of clients who have had a MedsCheck2 or MedRec completed upon transfer to long-term care

Indicator number: i4
Number of clients with completed MedsCheck or MedRec on transfer to long-term care
Total number of clients transferred into long-term care
Percentage of clients who have had a MRA3 completed upon in-take

Indicator number: i5
Number of clients with a completed MRA
Total number of intake clients
Clinical Processes Percentage of MRAs that lead to a pharmacist CMR4/ MedsCheck referral

Indicator number: i6
Number of clients who receive a pharmacist CMR triggered by an MRA
Total number of clients with completed MRA
Percentage of pharmacist consults for a CMR completed

Indicator number: i7
Number of CMR referrals completed
Total number of CMR referrals requested
Percentage of MedsCheck referrals completed

Indicator number: i8
Number of MedsCheck referrals completed
Total number of MedsCheck referrals requested
Percentage of MedRec clients requiring more than one home visit to resolve medication issues

Indicator number: i9
Number of MedRec clients who needed more than one home visit to resolve medication issues
Total number of MedRec clients
Percentage of MedRec clients who received an intervention for proper disposal of expired/discontinued medications

Indicator number: i10
Number of MedRec clients who received an intervention for proper disposal of expired/discontinued medications
Total number of MedRec clients
Percentage of discrepancies resolved through MedRec

Indicator number: i11
Number of resolved discrepancies
Total number of identified discrepancies
Percentage of MRPs5 resolved

Indicator number: i12
Number of resolved MRPs
Total number of identified MRPs
Risk Mitigation Processes Percentage of medication incidents or near misses reported which stem from client's medication self-administration

Indicator number: i13
Number of medication incidents or near misses identified and reported by providers which stem from client's medication self-administration
Total number of medication incidents reported
Percentage of medication incidents or near misses reported which stem from nurse and PSW6 administered medications

Indicator number: i14
Number of medication incidents or near misses reported which stem from nurse and PSW administered medications
Total number of medication incidents reported
Client Outcomes Percentage of Adverse Drug Events that caused a visit to the emergency department

Indicator number: i15
Number of adverse drug events that caused a visit to the emergency department
Total adverse drug events reported
Percentage of clients with at least one discrepancy

Indicator number: i16
Number of clients with at least one discrepancy
Total number of clients who received MedRec
Percentage of clients with at least one MRP identified

Indicator number: i17
Number of clients with at least one MRP identified
Number of clients who received MedRec
Percentage of clients who fell that have had a medication review

Indicator number: i18
Number of clients who fell that have had a medication review
Total number of clients who fell
Percentage of clients who are taking psychotropic medications that fell

Indicator number: i19
Number of clients who are taking psychotropic medications that fell
Total number of clients taking psychotropic medications
Percentage of clients that reported they were involved in developing their care plan

Indicator number: i20
Number of clients who reported being involved in developing their care plan
Total number of clients responding to question
Percentage of clients who reported that they did not take medication as directed

Indicator number: i21
Number of clients who reported they did not take medication as directed
Total number of clients responding to question
Percentage of clients that reported they manage their medications better after an intervention (i.e., MedRec, MedsCheck, MRA, CMR)

Indicator number: i22
Number of clients who reported they manage their medications better after an intervention
Total number of clients responding to question
1 MedRec - also known as medication reconciliation, is a systematic process that involves taking a best possible medication history, noting discrepancies and getting them resolved (usually with the physician)-thus leading to an accurate medication list
2 MedsCheck is a ministry funded program where the community pharmacist reviews the patient's medication for understanding and proper use and provides them with an up to date medication list.
3 MRA = Medication Risk Assessment
4 CMR = Comprehensive Medication Review
5 MRP = Medication Related Problems
6 PSW = Personal Support Worker

Tools & Resources

Updated on October 30, 2014

Tools

Tools to optimize medication management in the home

Safe Medication Handling
Nurses as team players in home medication management
PSWs as team players in home medication management
Pharmacists as a team player in home medication management
Assessing risk from medications
Medication reconciliation (and Best Possible Medication history)
Polypharmacy
Engaging clients and caregivers in managing medications/adherence
General