Transitions of Care
Standard 3.0
3.0
Perform, Communicate, and Implement Findings from a Medication Reconciliation
Processes are in place to support a reconciled medication list at each care transition point, especially in the case of patients at high risk for care transitions.
Organizations can meet this standard by showing evidence that a comprehensive medical reconciliation assessment is completed, and that the following elements are included:
Compilation of a full medication history, including both prescribed and non-prescribed medications, from all available sources, including:
- EHR and discharge summary
- E-prescribing records
- Claims data
- Paper records from other sites of care and providers
- Pill bottles provided by patient or caregiver
- Self-reported from patient or caregiver
- Patient’s pharmacy
- Regular ambulatory care provider
Identification of patients who may be at high-risk for medication related adverse events or non-adherence. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7319010/
Review of medication history against active medications in the current setting to identify discrepencies.
Verification of medication list accuracy with patient or caregiver, including non-prescribed medications, over the counter medications, and supplements.
Address medication discrepancies and non-adherence issues.
Document all medication reconciliation activities in the medical records, using applicable coding.
Advise and instruct on proper disposal of unused or expired drugs.
Roles & Terms
The treating provider (MD, DO) involved at the time of transition must be the party who is accountable for the reconciliation. The medication review may be performed by a designated clinical team member. The clinical pharmacist is uniquely qualified to make recommendations to optimize medication therapy and avoid potential adverse events such as drug-drug interactions.
Non-licensed providers may gather information but should neither perform medication reconciliation nor provide clinical recommendations.
Ambulatory Care Provider
The care provider who provides regular ambulatory care to a patient outside of an acute or institutional setting. This may be a PCP, APP or other licensed health care provider appropriate to the setting.
Transitions of Care
Funding and support for the Transitions of Care initiative is provided by