Medication discrepancies, or differences between what medications patients think they should be taking and the regimen collectively ordered by their healthcare providers, affect up to 70% of patients following hospital discharge. Older Veterans are particularly at risk, owing to multiple comorbidities and complex medication regimens. Frequently there are delays in resolving medication discrepancies, which are major contributors to adverse drug events (ADEs). Among older Veterans 33% experience an ADE in the first few months after hospital discharge, substantially increasing their risk of hospital readmission. Medication reconciliation, the proces of identifying the most accurate list of medications a patient should be taking, is an important strategy to reduce potentially harmful medication discrepancies, thereby improving medication safety. After hospital discharge, home health nurses are well-positioned to perform medication reconciliation;indeed, they are required to document discrepancies and alert the treating physicians. Though more older Veterans are utilizing home health services each year, little is known about the process and effectiveness of resolving medication discrepancies in the home healthcare setting. Currently, there is no standardized approach for home health nurses to identify, prioritize, and communicate discrepancies to the treating physician(s). Furthermore, prolonged time to resolution of discrepancies places older Veterans at increased potential harm due to medications. Therefore, tools to improve medication reconciliation are needed. My long-term career goal is to be an independent investigator whose discoveries improve the processes and outcomes of care transitions for older Veterans. This career development award will allow me to gain greater expertise in hospital discharge transitions and medication reconciliation, advance the methodology in measuring discrepancies, and design and test a pilot intervention to enhance home-based medication reconciliation.
The specific aims of the research are to: 1) Observe and document variation in the process of home health medication reconciliation using both qualitative and quantitative methods. I will observe the steps to complete medication reconciliation for older Veterans recently discharged from the hospital in order to document the variation in current practice. 2) With input from relevant health care providers, develop a medication reconciliation protocol for identifying, prioritizing, communicating, and resolving post discharge medication discrepancies in a timely manner. Focus groups will inform development of a protocol to help home health nurses prioritize which medication discrepancies are most clinically important and shape the communication tool to standardize how medication discrepancies are communicated to physicians. 3) Evaluate the feasibility, acceptability, and effectiveness of the reconciliation protocol and communication tool on reducing the time to resolution of post-discharge medication discrepancies. This pilot will set the stage for a larger, more robustly funded study of the intervention's effectiveness. The training program and mentored research activities will achieve the following objectives: a) advance my methodological skills (both qualitative and quantitative) through didactic training and experientia learning;b) gain additional expertise in implementation science and geriatrics through a series of educational experiences, as well as participating in journal clubs and research meetings;and c) develop, implement, and evaluate tools to improve medication safety after hospital discharge with guidance from an interdisciplinary team. All of the award activities will take place in a vibrant and supportive scientific environment grounded in the VA Geriatrics Research and Education Clinical Center (GRECC). In summary, by completing this career development award I will acquire indispensable skills and experience applicable to conducting future translational studies that improve medication safety for older Veterans, thereby possibly reducing hospital readmissions.

Public Health Relevance

After hospital discharge Veterans who need home health care are at increased risk of harm due to unintentional differences between what medications they think they should be taking and the medications ordered by their healthcare providers. Older Veterans returning home may be at particular risk for unintentional medication discrepancies because they have multiple medical conditions and take numerous medications. Home health care nurses are required to identify the most accurate list of medications a Veteran should be taking and document discrepancies at the first home visit. However, the resolution of discrepancies is often delayed and poorly coordinated. In this career development award the candidate will acquire additional training in implementation science and geriatrics, build methodological skills, and apply the training to improve medication reconciliation for older Veterans receiving home health care, thereby reducing the risk of harmful medication errors after hospitalization and possibly reducing hospital readmissions.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (IK2)
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HSR&D Career Development Award (CDA0)
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Veterans Health Administration
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Mixon, Amanda S; Neal, Erin; Bell, Susan et al. (2015) Care transitions: a leverage point for safe and effective medication use in older adults--a mini-review. Gerontology 61:32-40