Thirty-seven-year-old Mr. Smith was referred to the case management program due to a recent hospitalization for major depression and anxiety with comorbid conditions of hyperlipidemia and hypertension.

As a case manager, you meet with Mr. Smith. During the initial assessment, Mr. Smith reports taking the following medications: Lexapro (10 mg); Lipitor (20 mgs); “Blood pressure medicine. It’s yellow but I can’t remember the name.”; and Vicodin “that I take every now and then for back pain.”
The facility forwards medical information that indicates discharge/medication orders as:

• Lexapro 20 mgs po qd.
• Lipitor 10 mgs po qd.
• Inderal 80 mgs po BID.
• Tylenol (over-the-counter) as needed for back pain.

There are two physicians involved in Mr. Smith’s care: the psychiatrist and a family physician. What next steps do you take for the discrepancies of the medication as noted?

Reconciling Medicines, Reforming the System

The fragmentation of healthcare is a historical and disparaging anomaly of our country’s vast system. This reality is well known to healthcare professionals, including professional case managers.

In fact, the case management industry is often the piece of the healthcare system that attempts to “glue” the fragmented pieces together through collaborative efforts and coordination of care for each individual patient.

The enormity of “fixing” the healthcare system almost defies comprehension, whether we are consumers of that healthcare or professionals working within the system itself. Systems can only be changed by combining individual efforts connected by a cohesive goal.

Therefore, if the ultimate goal is to defragment a system, then the impact of each case manager’s efforts can only be realized when the industry performs to basic quality standards that help to defragment that care. One such step is to effectively address medication oversight in an easy-to-manage process.

Version 4.0 of the URAC Case Management standards addresses the issue of medication safety. There are numerous steps, both from organizational and individual perspectives, that can ensure a quality process for medication safety, including:

• Discuss and review the definitions of medication safety and medication reconciliation per the URAC and Institute for Healthcare Improvement definitions (see URAC CM 23).
• Compare those definitions with your organization’s policies and procedures on conducting assessments. Be sure to get the medical director or senior clinical staff person involved with this issue. Is medication adherence, knowledge and the need for medication reconciliation being done as a matter of policy?
• Complete a detailed review of your computer screens (or hardcopy files). Do the screens (or forms) allow room for or provide the ability for clear documentation of:
  • All current patient medications, including name, dosage, frequency and route?
  • Patient’s knowledge of each medication?
  • Patient’s adherence to medications?
  • The need (or not) for medication reconciliation?
  • Are these computer entries “mandatory” fields?
• Review organizational training materials: How are staff trained about the expected documentation of medication safety issues, including adherence, medication knowledge and the need for medication reconciliation?
• What steps would a case manager take if she found the possible need for medication reconciliation? What red flags might trigger further review? Should they discuss the issue with their supervisor? Should the medical director be notified? What notifications would be sent to the attending physicians and the patient (verbal or written)? Do your policies explain step-by-step what staff should do in this case?
• Quality oversight: What process is in place to ensure staff are clearly documenting medication knowledge, adherence and the need (or not) for reconciliation in the initial or subsequent assessments? Are these issues quality-checked on a regular basis?
• As a healthcare professional, would your documentation stand up to peer review? If another case manager or clinician were covering for your patients while you are “on vacation in Aruba,” would the next clinician clearly understand your documentation? Is it complete, current and accurate?
• Documentation of these elements must be addressed at all transition points of care, including the transitioning into and out of (or through) the case management process. Do policies and procedures and training materials address different points of transitions of care? Do computer screens flag, task or prompt further actions before, during and after transition points? What steps should staff take when a patient’s policy terminates or is no longer eligible for coverage? Does your organization support coordination of care with external entities, including transferring of care to another group of case managers?

Quality processes must be fervently used by organizations to help support individual healthcare professionals in either the clinical or the office-type settings. Only then can individual actions be performed on a routine basis to effectively impact and defragment the healthcare system as a whole.

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Bonnie Zickgraf is an accreditation reviewer with URAC with areas of specialties in case management, health utilization management, workers’ compensation, utilization management and others. (bzickgraf@urac.org)