From Polypharmacy To Clarity: Building A Culture Of Ongoing Med Rec

A single, accurate medication list can prevent harm, yet it’s often the messiest part of home visits. We unpack how to turn a kitchen-table pile of bottles into a clear, living record that protects patients, reduces polypharmacy, and keeps agencies compliant. Drawing on decades at the bedside and in surveys, we walk through the moments where discrepancies hide—transitions between providers, “as needed” meds, herbals and supplements, dose tweaks after a clinic visit—and show how to bring everything into alignment with orders and what’s actually in the home.

View CHAP's new resource: Medication Reconciliation in Home-Based Care

We get specific about what good medication reconciliation looks like in home health and hospice: verify at every visit, include non-covered and OTC products, and escalate discrepancies to the prescriber right away. You’ll hear why misalignment across the home list, the medication profile, and facility records is a top CMS deficiency and how it can escalate to immediate jeopardy when safety is at risk. We also dig into the April 2024 Home Health CoP interpretive update that lets agencies define who performs medication reviews based on scope and policy, while underscoring the nonnegotiable goal: a timely, accurate, and complete list.

Education and tools make the difference. We share practical strategies for teach-back, multilingual materials, and adapting for hearing or vision limits. We cover the Beers Criteria for older adults, ISMP resources, safe storage and disposal, and tech that improves adherence—delivery services, synchronized refills, pre-filled packs, and smart dispensers. Expect actionable checklists, questions to ask on every visit, and a reminder to have patients carry a current list to appointments and during any transition of care.

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Transcript

Welcome And Topic Set: Med Rec

SPEAKER_01 0:14

Greetings, I'm Jennifer Kennedy, the lead for compliance and quality at CHAP, and welcome to this edition of CHAPCAST. So, what we're going to be talking about today is medication reconciliation. And I'm so glad to be back in the podcast saddle with my sidekick and friend and colleague Kim Skian. And Kim, you know what? I think this topic is always timely and it is such a big deal in order to get MedRec correct. So let's just go ahead and jump right into it, unless you have any pre-thoughts that you want to throw out there to our listeners before we jump into it.

SPEAKER_00 0:59

Absolutely.

Why Medication Reconciliation Matters

SPEAKER_00 1:00

And the only thing that I um I'm thinking is, you know, we are work seasoned, home health and hospice and RNs will say that after, you know, four decades of so or so. And then the entire time, yeah, in the entire time that we have uh been, certainly in this industry, probably long before that, and since then, every clinician in every setting faces this issue, this medication reconciliation issue is just so important. And uh it's something that, as you said, is really timely and timeless. So I think this is really a great topic for today. So thanks for having me. Absolutely.

SPEAKER_01 1:45

So, Kim, why do clinicians and organizations need to pay attention to this? Why does it matter so much?

SPEAKER_00 1:54

Well, first and foremost, it remember that this this really reflects and and and targets patient health and safety. Patient safety is paramount. And over the many years, uh, with progression with medications, so many medications on the market, so many different medications, cross-setting with different, you know, different um different settings that the patient may be visiting or being cared for, really can result in a lot of uh confusion and frankly danger, you know, for the patient if there are issues, if there are issues that are not addressed in terms of medications, duplication, omissions, um, lack of clarity, you know, all of those areas. So it really is crucial. Um, the medication reconciliation process is crucial to ensure that the safe and effective use of medications are is is uh being reviewed, identified, and resolved at the time of assessment, not just and we'll talk about this, I know, not just at the time of initial assessment, but ongoing throughout care.

SPEAKER_01 3:07

Yeah, you know, that's that's exactly it. And uh, you know, you know me, Kim, I do a lot of reading, I read a lot of articles and things of that nature.

Real-World Risks And Survey Deficiencies

SPEAKER_01 3:16

And with our older adults wanting to age in place, stay at home, receive home services, you know, it doesn't mean that they're necessarily going to have the capacity mentally to manage medications, especially if they're seeing multiple physicians, each physician is prescribing, um, and maybe, or maybe they don't have a caregiver to help them out with that. Uh, I feel like the sort of the continuum of health care that some older adults are experiencing absolutely could lead to safety issues around taking their medicines. So, and I just stated myself by saying their medicines, I know that. Um, but you're right. I mean, it's so much a safety issue. Um, and and I know both you and I are no stranger of going on a home visit and saying, show me all your medications, and they put a big old shopping bag on the kitchen table, and you're you know, taking 30 minutes to sort through everything, you know, like it in from 1973, all that, right? So um it's huge, it's huge. And um there are, I think, really some big questions that organizations need to be asking um about uh the importance of requiring consistent medication reconciliation from their clinicians.

SPEAKER_00 4:49

Yep, absolutely. And from a survey standpoint, again, um survey and uh medication, medication discrepancies between the documentation in the home, what the patient's taking, the medication profile, physician orders, um, and if in a in the case of a organ a patient serviced in a facility, such as for hospice, but also ALF assisted living facility for home health, for example. You know, if we don't, if you don't have that the alignment, that is one of our top uh survey deficiencies, not just for CHAP, but for all of CMS, um as well, all CMS state agencies, you know, when we look at all of the top deficiencies. And the other component here is that it also, depending on the type of discrepancy and or the actual or potential impact on the patient, it can be a certainly a condition level deficiency, but also immediate jeopardy when patient safety is at risk and there's there's a then medications are um are at stake or involved. Um so this that's why this is another reason why, in addition to patient safety, organizations need to understand how how important this is for clinical practice and for compliance.

SPEAKER_01 6:19

So the act of you know, nurse, whether it's you or me or somebody else, going into somebody's home, taking that time to take the medication list.

Building A Complete, Accurate Med List

SPEAKER_01 6:31

Um it let's say it's an admission and and you have uh maybe a discharge summary from a hospital, and um you're taking that list and matching up against what the uh patient has in the house, and then maybe you're finding more things, you know, herbals and um nutraceuticals and um uh you know, recreational marijuana is a thing now. You know, all of those things have to be uh looked at in order to make an adequate and complete um drug list. And you know what? I think the question that I particularly in hospice that has come up uh for me in my career is people asking, hey, if we're not um facilitating the prescription or in a hospices case, providing the drug, does it go on the drug list? And the answer is yes. Even though you're not paying for it or supplying it, it absolutely has to go on that list. Um, because that's the only way you're gonna be able to see the scope, I think, of what that patient is actually taking for sure.

SPEAKER_00 7:47

Absolutely. Yep. And that does apply, hospice, home health, really any setting. And also I would add that, as I said, this it's not just um the initial assessment, although we know that certainly in home health, there's the timeline to be in OASIS to be reconciling those medications with the physician. Um, but that's a standard of practice. So it really any discrepancies need to be clarified with the uh physician, the the prescribing physician, um, at the time of identification, but not not forgetting that medication reconciliation is an ongoing process. And you and I both know, and we've said it many times, as have others, that really a best practice recommendation is for the primary care clinician, so most often that's an RN, um, but we also may have home health where there may be a therapist, a physical therapist, right, um, to at least make sure that the medications

Ongoing Process Beyond Admission

SPEAKER_00 8:53

align altogether, as I said, with the documents in the home, the what the patient's taking, and um, you know, and the the med profile and the orders. And and many, many, many times, I'd say probably uh most commonly during home visits, during a survey, when that question is asked, when the surveyor or site visitor in our case conducts, has the nurse conduct a medicate medication reconciliation, there's there's very often a discrepancy because the question that had been asked prior to that surveyor coming would have been the clinician asking the patient, have you had any med changes since my last visit? And of course the patient's gonna say no, you know, if they you know don't think about an over-the-counter medication they took or an adjustment to LASIKs, for example, or another med that happens, you know, a month or two ago. So um, so it's it's really important to make sure that the that the age that your organization, hospice, home health, home care, honestly, home care if you're providing skilled care, you know, making sure that there is a regular process for evaluating and updating that medic those medications.

SPEAKER_01 10:13

Yeah, I I couldn't agree

Older Adults, Polypharmacy, And Safety

SPEAKER_01 10:15

more. And uh when we're looking at particularly again with the older adults, um, whether they're receiving home health or hospice or home care, uh, getting that list, that complete list, in order to show it to either the primary care physician or the hospice doc or the pharmacist, so that they can look at things like drug interactions or maybe see drugs that are on a the beers list that might uh you know could be knocked out for uh older adults because it's a safety issue. Um and you know, some herbal medicines don't gel with prescription medicines. So having that uh that complete list for that next um intensive review of the of the drugs is really critical uh because then we can uh proactively um not have any kind of um uh drug problems if that is completed uh in in the right way. And uh I agree with you. I think it's every visit, that's standard practice. We know that either people sneak away to the doctor and they forget to tell us, or they have a family member that says, you know, here I saw this Nereva on TV, and mom, you should be taking this, you know, and uh all of those things. So um it's it's not only a safety issue, it's it's really a quality of life issue as well, because you want your patient to feel good either in their recovery period with you if you're uh providing those kinds of services, or that they're comfortable uh if they're at end of life. So um uh yeah, I I feel pretty passionate uh about this uh issue. And um I I think maybe uh organizations out there may need to put this on as an evaluation, maybe for a performance improvement project if if they're not uh getting a handle on it.

SPEAKER_00 12:24

So I agree with that completely.

SPEAKER_01 12:28

So, Kim, when we talk about home health specifically, um, what would you say are some of the benefits of doing good consistent Med Rec?

SPEAKER_00 12:37

Well, first and foremost,

Compliance, Alignment, And Immediate Jeopardy

SPEAKER_00 12:39

ensuring accuracy of the um of the medications, of the medication list and understanding the medications that the patient is taking. And I know again I'm using med medications, but whether it's um uh you know from prescription, non-prescription, as you said, you know, or um herbal remedies, so that we have a true understanding of whether you know what the patient's taking, to your point, what may need to be reported to the physician in terms of potential polypharmacy, um, interactions, uh, contraindications. But really, it's part of the comprehensive assessment, evaluating patient needs, both on initial assessment or initial comprehensive assessment, and ongoing, to make sure that we're looking at the appropriateness and the effectiveness of those prescribed medications, monitoring that adherence, especially when we're teaching on meds or there are med changes, to make sure that we um that that the clinician is assessing um again the effect, and also the patient education education to patients and caregivers, giving information about medications and including, you know, dosages, side effects, for example, but also you know, there are some other resources. You mentioned the BEARS criteria, um, but there also are um, you know, uh includes resources for help in terms of patient guides, you know, as well as the Institute for Safe Medical Pract Medication Practices. So, you know, agencies, hospice, home health agencies need to make sure, as well as hospices, need to make sure that they have that that those updated resources and that their staff have updated information. And the other reminder, again, I alluded to it before, but related to um home health specifically, when the home health conditions of participation were appendix B was updated in um or revised April of 2024, they removed the line in the interpretive guidelines that's that stated that uh an RN or a qualified nurse needed to uh review um any medication, uh, medication reviews or assessments, uh, medication lists uh that were provided by a therapist. So the organization defines based on state scope of practice, state regulation, and agency

Reconciling Across Settings And Substances

SPEAKER_00 15:19

policy what the medication review process is. And it still may have, there still may be a process, you know, for the organization may choose to have an RN or a nurse, you know, um conduct, you know, conduct the further follow-up if there's a question. But but the a you know, the agency does have the ability to be able to determine the best way to make sure that that information is updated, ongoing, and that's the most important um aspect of med reconciliation.

SPEAKER_01 15:52

Absolutely. And you know, I thought of one other thing, although I know we don't want to go down this rabbit hole on this podcast, is that in addition, um, you know, one thing you could learn from doing consistent med rec is, you know, if a patient is taking um narcotic medications, if there's any kind of drug diversion happening in the home, um, that could actually be something discovered through consistent med rec as well. Um that's a whole nother podcast, I'm thinking, Kim. I don't know about you. Yeah. Yeah. All right. I agree. So um when we're talking about what providers should be doing, there's a list of questions that I think about as a nurse that are related to medication reconciliation. I'm sure you're thinking about the uh a similar list as well. And um, what are some of those questions that nurses should be asking if they're the primary person uh doing that med rec on visits?

SPEAKER_00 16:59

Well, again, um, you know, first of all, making sure that they are uh evaluating and reviewing all of the medications that the patient is taking. Uh, you know, even if that's a an as needed, a PRN medication, we have to make sure that we know the medications that the patient is taking. Um, if they're not taking medications, in other words, like you said, the you know, Vicodin from 1973, you know, again, you know, making sure that we're, you know, working with them, you know, confirming with the physician, but working with them, with the patient to educate them on drug disposal, um safe drug disposal, um, so that they can clean up all of the old medications. We know many patients, especially older patients, have penicillin or you know, antibiotics or pain medications, not because they, you know, they're stocking up for narcotic use, but because it's just in case I need it. So, you know, we really have to differentiate to be able to make sure that we're clear on what the patient is taking and also educate on safe medical practices, um, medication practices. So

Every Visit Verification And Quality Of Life

SPEAKER_00 18:14

in looking at not just the med list, it's the med list in the home, the actual medic uh, you know, uh drugs in the home, medications, and as well as again, what's and what's ordered, you know, to look at the whole picture and making sure that the patient and um understand patient and caregivers, um, if they have them, understand their medications and can safely administer their medications. Because we also know that if patients are, or caregivers sometimes, if they're responsible for you know administering their own medications or pre-filling medications, assessing to make sure that they that that that all parties have an understanding of you know what they're supposed to be pre-pouring or administering and at what times, and not, you know, because we've definitely seen issues with with that in terms of over-medication or under medication because of a lack of understanding. Also, again, making sure that there are um adequate medications on hand. Do they have enough medications? And this is you know, prescription or non-prescription, if they're regularly taking them. And we know for hospice, we order through the pharmacy, right, through hospice, but for home health, you want to make sure that that you know you're um working with the the the patient and family to make sure that they are ahead of the um of the you know of the medication need. Also, as part of patient and family education, what are some of the alternatives for receiving medications? So if you have a patient who has dementia or has some sort of memory impairment or cannot get out of the home, um, then having medication delivery services or you know, the pre-filled medication boxes or um the electronic, you know, dispensing in the home. There are so many opportunities these days with technology that that you know we uh as clinicians need to first and foremost make sure we know what medications the patient's taking, but then on top of that, identify the best way for them to be able to get the medications that they need.

SPEAKER_01 20:40

Yeah, you know, and you there's one thing that stuck with me. You're talking about educating the patient and the caregiver or the family member. And

Benefits For Home Health Outcomes

SPEAKER_01 20:48

um, we all know that that's really important, particularly if the patient doesn't have mental capacity. But um, we have to figure out how they best learn and give give the information, I think, in in multimediums. You know, we're gonna tell them, we're going to give them something in writing, and we have to consider health literacy and actual literacy issues when we're you just can't say, here's the sheet, right? You have to do a little more than here's the sheet about your medicine. Um and uh you know, suggesting that someone does go with that patient to their appointments and and things of that nature. So it's talking about individualizing that portion of the plan of care even a little bit more than um just saying, take this at this time on this day, and here's the um here's the education sheet about it. Um so uh I think we need to be more thoughtful as uh providers to how people best learn and um uh making that a good match for them as well.

SPEAKER_00 22:02

And Jen Jennifer, I would also add that it also that any sort of education does need to be provided in a language or a method that the patient and family understand. So if it's a form a foreign language or you know, hearing impaired or sight impaired, you know, um, to be able to make sure that the um that you know that the the the people who are receiving the the education and the training um understand that, comprehend. And also I I think you have a great reminder about you know one of the key, I think, components of education, in addition to safe storage and making sure they have the right medications and the purpose of the meds, you know, et cetera, um, signs and symptoms of side effects, for example. But the one of the big things is also making sure that whenever they are uh at an with another practitioner, whether it's a transition to an ER or it's to the

Resources, BEERS, And Practice Updates

SPEAKER_00 23:05

medical, any of their uh physicians or you know, practitioners that they're seeing, to make sure that they have a current medication list with them because you know they want to make sure that they that they that the patient, that that the the clinician or whatever setting the patient is being seen in has an accurate description. And I know in this day and age, you know, health systems have you know charts, you know, electronic charts that speak across um across the different settings, but you may be in a setting outside of the um you know of of that particular enclosed health system, or um the if even though it's accessible to the clinician the the clinician in this in the healthcare system, the patient may not have a true understanding of what they're actually taking. So having an actual actual written list taken with them to their appointments or any transition of care, I think is extremely important.

SPEAKER_01 24:11

Yeah, can't uh recommend that enough. Absolutely. So, Kim, as we uh get to the end of our uh medrec discussion today, are there any thoughts that you want to finish out with uh on this topic or um any piphanies or anything that comes to mind for our for our listeners out there?

SPEAKER_00 24:35

You know, Jennifer, I think this is another topic that you know you and I, and certainly many people in our industry, could have a far more lengthy discussion on because it is so important. And I think just keeping in mind that our primary focus, again, is the health and safety of patients, and remembering that medications is a key element of that, you know, of caring for these patients. So just you know, I I feel like there are resources and um certainly these reminders that are very helpful, but each organization and each clinician needs to have a clear understanding of what their role is and how important it is to ensure patients' medications are um accurate.

SPEAKER_01 25:26

And I'm really excited that we uh that you and I developed our medication reconciliation resource recently, and that we're gonna uh be pushing that out the door uh shortly. Uh, talk about multimedium. So we're doing the podcast, and then we're gonna push out a written resource uh for our um for our customers as well.

Role Definition After 2024 COP Changes

SPEAKER_01 25:50

So uh thanks for working on that with me, and hopefully uh we'll do uh some additional medication resources down the line. Um but I think that one will help. Uh, whether you're um a seasoned clinician, whether you're a new clinician, uh it's you know basically the basics of medication reconciliation. So look for that soon. We'll be posting that out on our web page. Well, thank you, Kim, so much for talking with me today about medication reconciliation. Um I know that we could probably talk probably an hour more and tell some good stories about things we've seen in our almost four decades of nursing practice. Um, and I just again I think this one is um it's not a heavy lift to do, and it's so important. And um, we just have to make sure that we take the time uh in every visit to uh pay attention to that so that our patients remain safe and have good quality of life. So thank you to all of you for taking time out of your day uh to listen to our podcast about medication reconciliation. From Kim, me, and the entire CHAP staff, keep your quality needle moving forward, stay safe and well, and thanks for all you do.