Medication Reconciliation and Care Coordination

 Care Coordination 
 CMS Demonstration 

Agency
Concord Regional Visiting Nurse Association in Concord, New Hampshire.

Agency Description
Concord Regional Visiting Nurse Association (VNA) is a not-for-profit, community-based health care provider that serves people of all ages in central New Hampshire. Services provided include home care, hospice, personal home services, maternal and child health services, pediatrics, and community health services. 

Goal of Project
Reduce hospitalizations for Medicare patients with multiple chronic conditions and multiple medications. 

Population Impacted
Those impacted by this project include Medicare beneficiaries, people who have chronic health conditions and multiple barriers, including polypharmacy and limited support systems, and multiple providers of care (primary care providers and subspecialists). 

Strategic Partners
Concord Regional VNA worked with Dartmouth-Hitchcock Concord physicians and additional clinical staff. Dartmouth-Hitchcock screens patients for inclusion in the program and works with the Concord Regional VNA’s Nursing Care Coordinator to reconcile medications and coordinate care through both electronic communications and face-to-face meetings. 

Project Description
In January 2012, Dartmouth-Hitchcock Medical Center was named a Pioneer ACO. Concord Regional VNA was exploring options to integrate the agency into a Medical Home Model to better serve Medicare beneficiaries who are at high risk of being rehospitalized. In this program, rehospitalization is defined as when a patient is admitted back into the hospital within 30 days of the initial hospitalization for the same illness. Concord Regional VNA’s Home Health Nursing Care Coordinator consulted with three Dartmouth-Hitchcock Medical Center Primary Care Providers (PCPs) to form a pilot group. The pilot group began to study Dartmouth-Hitchcock’s patient population and identified the need for medication reconciliation. Clinical support was requested and the group developed methods to capture critical data needed to best serve patients. 

A pilot study started and developed a scope of service. The pilot has since expanded to include Dartmouth-Hitchcock Concord PCPs. 

Dartmouth-Hitchcock withdrew from the Pioneer ACO model and is now a Next Generation ACO.

Results
The results of this study found that measures of success included improved patient education and enhanced relationships with providers regarding post-acute care. Concord Regional VNA and the PCPs shared information about patients and also quality metrics utilizing information technology, which allowed access to each organization’s records. This data sharing and technology allowed providers to improve care and communication.  

Outcome Measures
During the first year of the project, Concord Regional VNA served 204 patients and made significant changes to quality reporting. The measures Concord Regional VNA reviews include patient satisfaction survey results, readmission rates, emergent care rates, reduction in medication errors during transitions of care, and the OBQI score for improvement in medication management. Concord Regional VNA created a note to track specific medication issues found during the medication reconciliation visit and interventions completed by the clinician. For this patient population, the rehospitalization rate was reduced from 27 percent to 24 percent. Other metrics addressed were: 1) Patient ability to take oral medications correctly increased from 38 percent to 58 percent, and 2) Patient satisfaction on specific care issues increased from 81 percent to 87 percent. 

Barriers to Implementation
Concord Regional VNA encountered many barriers to successful implementation of the program. These included lack of communication, both between patients and providers, as well as electronic medical records incompatibility. Regulatory compliance issues also created barriers. Concord Regional VNA does not bill the medication reconciliation visit but needed to understand the scope of the visit from a nursing practice scope perspective. The nurse does not perform any hands-on care other than the medication reconciliation and assessment of the environment during the visit. If the nurse identifies a need and home care is not already ordered, then the clinician requests a home care referral. Concord Regional VNA did not receive or secure any grants to fund this project. Lack of funding restricted some program aspects. Finally, patient refusal of care was a huge barrier to complete this project. Patients refused care primarily because they did not feel they needed a visit. Concord Regional VNA experienced an increase in compliance when the physician practice called the patient and told them that their "physician ordered" the visit.