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Medication Reconciliation for Older Adults Transitioning from Long-Term Care to Home


Annals of Long-Term Care: Clinical Care and Aging. 2011;19[8]:25-29.


Allison (Leverett) Kackman, MN, RN; Cynthia F. Corbett, PhD, RN; Lorna Schumann, PhD, ACNP-BC, NP-C, ACNS-BC, CCRN, ARNP, FNP, ACNP, FAANP; Stephen M. Setter, DVM, PharmD, CGP

Gone are the days when general practice physicians woke early to round on their hospital and long-term care (LTC) patients prior to their first clinic appointments. Today, it is nearly impossible for primary care providers to maintain a thriving ambulatory practice and still find time to attend patients who are hospitalized or residing in LTC facilities, which means many patients admitted to LTC facilities for short-term rehabilitation have received care from a multitude of providers in several settings prior to being discharged to home.1 Medication regimens for these patients often change numerous times during transitions in care, which might include from home to the emergency department (ED), from the ED to an inpatient unit, and from the hospital to a LTC facility. Thus, when patients in short-term rehabilitation are ready to be discharged to home, medication reconciliation is a critical intervention. Medication reconciliation is defined as “the process of identifying and correcting medication discrepancies to make two or more medication lists congruent.”2

Studies have identified medication reconciliation as the most important means of decreasing or eliminating medication discrepancies.3 Failure to perform medication reconciliation may leave patients and caregivers confused about the proper medications to take at home, which can lead to harmful errors. At least 1.5 million people annually suffer adverse drug events as a result of medication errors.4 The Patient Safety Management Framework (Figure) can serve as a guide for conducting medication reconciliation for LTC patients who are being discharged to home.



Importance of Medication Reconciliation

As patients transition through acute and LTC facilities, the multitude of care settings and providers involved, combined with patients’ ever-changing acute and chronic conditions, creates a “perfect storm” for transition-related medication problems. Healthcare professionals are responsible for tracking and administering medications, and as a patient moves from one facility or provider to another, it is extremely important that all medications be reconciled. The literature demonstrates, however, that healthcare professionals do not always do so accurately, which increases a patient’s risk of drug-related adverse events.5 Studies estimate that >1,700,000 preventable drug-related injuries occur each year, including 400,000 in hospitals, 800,000 in LTC settings, and 530,000 among Medicare beneficiaries treated in outpatient settings.4

During transitions of care, patients and caregivers generally do not keep up-to-date on changes to medication regimens, making it especially important that the healthcare provider reconcile all medications thoroughly for patients being discharged to home. This is especially true for older adults with chronic conditions, who are often taking five or more medications. As the number of medications increases, the potential for mismanagement increases. Factors commonly associated with old age, such as cognitive decline and low health literacy, can also inhibit a patient’s ability to understand and successfully implement medication management once he or she has been discharged.

A study by Delate and colleagues6 evaluated the outcomes of patients receiving medication reconciliation during the transition from LTC to home and found a 78% reduction in the risk of medication-related deaths for those who participated in the intervention. Although research shows that pharmacists are the most effective at performing medication reconciliation,7 their role in LTC has generally been limited to monthly medication reviews. When older adults are discharged from LTC, it generally falls on nurses to lead the medication reconciliation process, yet few studies have examined the nurse’s role in facilitating medication reconciliation in the LTC setting.

Literature Review

To identify “best practices” of medication reconciliation for patients transitioning from LTC to home, we conducted a thorough search of available literature from 1992 to the present using PubMed, CINAHL, Medscape, and Google Scholar search engines. The literature search
revealed only one study on medication reconciliation during the transition from LTC to home.6 In this study, a pharmacist worked with a primary care provider and a chronic condition nurse to augment the usual transitional services. The process included evaluating the previous 24 months of prescription data for drug names, dosages, fill dates, drug history, and current discharge medication information, as well as educating patients on their drug regimens and potential adverse effects. An adjusted analysis of outcomes data found a decreased risk of death in the 60 days after discharge for the cohort of patients who received medication reconciliation.

Due to the lack of published research on medication reconciliation during transitions from LTC to home, literature on transitional care for patients discharged from hospital to home was evaluated to discern strategies that might be applicable to LTC. Four prominent models for improving transitional care were identified, each of which incorporated medication reconciliation practices.

Four Models of Transitional Care

In the Transitional Care Model, medication reconciliation strategies are initiated during hospitalization and continue after the patient returns home, with at least one post-discharge visit.8 Prior to hospital discharge, the Transitional Care Nurse (TCN) collaborates with the primary care provider and the pharmacist to eliminate unnecessary medications and provide a plan for safe administration and identification of adverse side effects. The patient is educated on the plan at the time of discharge. Once the patient is home, the TCN makes one or more visits to evaluate medication use in the home setting and again collaborates with the physician(s) and pharmacist as needed to ensure safe medication use in the home. The TCN also generally accompanies patients/families to their first post-discharge primary care appointment. This further enhances the exchange of health information and solidifies the medication reconciliation process.

Project RED [Re-Engineered Discharge] is another model that attempts to reconcile medications prior to hospital discharge.9 Patients are assigned a Discharge Advocate (DA), who first presents an electronic medication list to the patient and asks the patient to identify medications currently being used. Next the DA and the treatment team get together for a complete medication reconciliation meeting. Follow-up strategies include ensuring patients understand the purpose and proper administration of their medications, can identify drug-related adverse effects, and have a realistic plan for obtaining their medications after discharge.

The BOOST [Better Outcomes for Older Adults Through Safe Transitions] program uses a screening tool that helps identify risks factors for adverse events, such as psychological problems, polypharmacy, poor health literacy, weak patient support, use of high-risk medications, and inadequate understanding by the patient or caregivers about the implications of medication use. Based on the information obtained with the screening tool, risk-specific interventions are implemented. For example, the medication regimen of polypharmacy patients is carefully evaluated to determine whether any drugs can be eliminated or dosing can be simplified. Patients are also scheduled to receive a phone call 72 hours after discharge to assess medication adherence and identify any potential problems.10

The Care Transition Intervention takes a four-pillar approach that involves medication self-management, patient-centered records, follow-up, and identification of “red flags.” The intervention’s medication reconciliation process focuses on medication self-management and evaluating the causes  of and contributing factors for medication discrepancies and their resolution. This involves the medication self-management pillar, which has initial goals of ensuring patients are knowledgeable about the medications they take and have a system for managing their medications safely. A designated representative visits patients in the hospital to provide medication education and discuss the importance of these self-management goals. Following discharge, patients receive a home visit to reconcile pre- and post-hospitalization medications lists. Finally, follow-up calls are made to patients to answer any remaining questions they or their caregivers have about medications.

Studies Suggest Cost Savings With Medical Reconciliation

All four of the transitional care interventions discussed have demonstrated reductions in acute care readmission within 30 days of hospital discharge and significant overall cost savings. Because each program discussed uses several strategies to improve the hospital-to-home transition, it is difficult to discern the unique contribution of medication reconciliation on subsequent acute care use and expense; however, data suggests that medication reconciliation is an important factor. For example, when the pharmacist in Project RED called intervention participants following discharge, the majority had one or more medication issues identified; the pharmacist took action, such as calling the primary care provider for order clarification, on behalf of 53% of participants.11

Research by Coleman and colleagues12 demonstrated that hospitalized patients found to have medication discrepancies at discharge were significantly more likely to be
readmitted. Additionally, a recent telephone-based transitional care intervention that focused only on medication reconciliation demonstrated a >50% reduction in 30-day and 60-day readmission rates and conservatively estimated an annual savings of $3.4 million for the 3694 patients involved ($920 per patient).13 


Continued on next page

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.

table 1

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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