Medication Reconciliation for Older Adults Transitioning from Long-Term Care to Home: Page 2 of 2

August 12, 2011

Best Practices for Medication Reconciliation

Our findings suggest that medication reconciliation strategies used in the aforementioned transitional care studies and in the study by Delate and colleagues6 represent “best practices” and consideration should be given to incorporating them (see Table for summary) in the care processes for LTC patients about to be discharged to home. In LTC settings, while an interdisciplinary team assists patients from admission to discharge with the goal of a successful transition home, it is the nurse case manager who is generally responsible for medication reconciliation and education prior to discharge. Although it might appear time intensive, combining the suggested best practices for medication reconciliation extracted from the aforementioned transitional care literature with the nurse’s professional judgment has the potential to improve medication safety following discharge.

Comparing Medications Between Home and Facility

The first step in the medication reconciliation process is obtaining a list of the medications the patient was taking prior to hospitalization. The home medication list obtained in the hospital is typically incorrect and incomplete. Patients and families, who are working primarily from memory, often omit medications or provide inaccurate dosing information. When the medication history provided at admission is incorrect or incomplete, it places the patient at high risk for medication problems after returning home. The best way to obtain an accurate list may be to ask family members, caregivers, or friends to bring any medication bottles found at the patient’s home to the LTC facility.

Procuring an accurate home medication list facilitates a comparison of drug classes that were used at home with those the patient is currently receiving in the LTC facility. Identifying duplicate drug classes is an important step in eliminating the possibility of patients inadvertently taking two medications for the same indication. When duplicative drug classes are observed, the nurse can work with the patient, caregiver, and physician to clarify which medication is preferred. Medication duplication, even when harmless, adds to healthcare costs. The next step in medication reconciliation involves clarifying proper drug dosages and administration frequency and identifying any new medications, as well as drugs that the patient has discontinued. After these steps have been completed, a new medication list needs to be drawn up and provided to the patient.

Updating the Patient’s Pharmacist and Primary Care Provider

Once the patient’s discharge medications have been reconciled with the home medications, the nurse should fax the updated medication orders, which include a list of all discharge medications and are signed by the primary care provider, to the patient’s pharmacy. This is an important step because the new order list provides the pharmacy with the most current list of prescriptions. This list also needs to detail all over-the-counter medications, vitamins, supplements, and herbal remedies used. The pharmacy can then update its database with the patient’s new medications, allowing new or changed prescriptions to be filled and avoiding refilling discontinued medications.

Pharmacists are legally mandated to review any new medication with the patient or caregiver. Thus, the outpatient pharmacist should be allotted time to educate the patient or caregiver about each new medication and address any questions or concerns. Education provided by the pharmacist serves to reinforce the medication instructions given by the nurse prior to the patient’s discharge from the LTC facility.

Communicating updated medication information and other medical details to the primary care provider is equally important. Faxing information on the patient’s discharge and the newly developed medication list, along with pertinent laboratory results, pending laboratory or diagnostic tests, and any other pertinent updates about the patient’s condition, will assist in bridging the gap between the patient’s primary care provider and all that transpired during the patient’s acute and rehabilitative care admissions.

Scheduling a follow-up appointment with the patient’s primary care provider should be considered part of the discharge process. Scheduling this appointment prior to the patient’s discharge from LTC facilitates patient follow-up and is consistent with the best practices in hospital-to-home transitions. Instructing patients, families, or caregivers on the importance of keeping the follow-up appointment and establishing transportation plans for getting to the appointment are also recommended.9

Patient and Caregiver Education

The most important step might be having the LTC discharge nurse educate the patient, family, or caregivers. This process ensures that the current medication list has been thoroughly reviewed and that the patient understands the purpose of each medication, which medications have changed from his or her home regimen, and which medications are new, and it can help reduce medication discrepancies and the likelihood of adverse drug events.9

The “teach-back” method is often used in transitional care education. In this approach, the nurse shares the new information with the patient or caregiver and asks that the recipient teach the information back to the nurse. Using this approach allows the nurse to assess the patient’s understanding of the instruction given. Ensuring that the patient or the patient’s family or caregiver understands the information and instructions provided may facilitate medication adherence at home.3,14

Another helpful practice is to use a medication list table and include the brand name and generic name for each drug on the discharge list; this minimizes confusion and the possibility of medication duplication. The purpose of a medication list table is to provide patients with additional information about each medication in an easy-to-follow
table format. As noted, medication brand and generic names are often included, as are the purposes for taking the drug, dosing instructions, common side effects, and the name of the prescribing provider. Many medication list tables are available online and LTC facilities often develop their own versions to use when patients are discharged.  Before returning the medication bottles brought into the LTC facility by the family or caregiver, the discharge nurse should separate those medications the patient is no longer taking from medications that are being continued and advise the recipient to dispose of any discontinued medications properly.

Benefits of Using Best Practices

Improving knowledge among patients and caregivers of a patient’s currently prescribed medications will lead to safer medication management once the patient has transitioned home, which is the overall goal of medication reconciliation. As suggested by the Patient Safety Management Framework, several care processes—or best practices—during patient transitions from long-term care to home can be implemented to improve medication safety. Reconciling the patient’s medication list and sharing the revised list with the patient, caregiver (if applicable), pharmacist, and primary care provider ensures that everyone has accurate information. Using the teach-back technique helps confirm that patients and caregivers have adequate knowledge regarding the purpose of the patient’s medications, their potential side effects, and the correct dosing and administration of each drug, thereby facilitating medication safety post-discharge. Improving the accuracy of transferred information and the instruction given to patients or caregivers on safe medication management could lead to better outcomes, including fewer adverse drug events, lower healthcare costs, and better quality of life for patients.


Medication reconciliation is a critical process for promoting safe, effective transitions in care. The Patient Safety Management Framework provides a theoretical basis for successfully approaching medication reconciliation for older adults transitioning through care settings during an illness. Implementing and evaluating theory-based strategies to improve medication safety for patients transitioning from LTC to home requires considering the antecedent conditions, the care structure, and the processes that influence the need for and outcomes of medication reconciliation. Such an approach will eventually lead to truly identifying “best practices” for medication reconciliation during the LTC-to-home transition.

Although research on the effectiveness of pharmacist-led medication reconciliation practices continues to emerge,6,7,13 the literature reflects an absence of studies addressing the nurse’s role in the medication reconciliation process during a patient’s transition from LTC to home. Since nurses are the health professionals most likely to perform medication reconciliation for patients transitioning from the LTC setting to home, research that evaluates the effectiveness of having nurses implement these suggested best practices (Table) at LTC facilities is recommended.  u

The authors report no relevant financial relationships.

Ms. (Leverett) Kackman is a family nurse practitioner and is employed at Family Home Care and the
Waterford Active Living Community; Drs. Corbett, Schumann, and Setter are associate professors, Washington State University, Spokane.



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