Optimizing Medication Reconciliation for Older Veterans in Home Health Care

描述（由申请人提供）： 药物差异，或患者认为他们应该服用的药物与其医疗保健提供者集体订购的方案之间的差异，影响了出院后高达70%的患者。由于多种合并症和复杂的药物治疗方案，老年退伍军人尤其面临风险。在解决药物差异方面经常出现延迟，这是药物不良事件（ADE）的主要原因。在老年退伍军人中，33%的人在出院后的头几个月内经历了ADE，大大增加了他们再次入院的风险。 药物协调，确定患者应该服用的最准确药物列表的过程，是减少潜在有害药物差异的重要策略，从而提高药物安全性。出院后，家庭保健护士能够很好地进行药物核对;事实上，他们需要记录差异并提醒治疗医生。虽然每年有更多的老年退伍军人利用家庭医疗服务，但对解决家庭医疗保健环境中药物差异的过程和有效性知之甚少。目前，家庭保健护士没有标准化的方法来识别，优先考虑和沟通的差异治疗医生（S）。此外，解决差异的时间延长使老年退伍军人因药物治疗而受到的潜在伤害增加。因此，需要改善药物协调的工具。 我的长期职业目标是成为一名独立的调查员，其发现改善了老年退伍军人护理过渡的过程和结果。这个职业发展奖将使我获得更多的专业知识，在医院出院过渡和药物和解，推进测量差异的方法，并设计和测试试点干预，以加强家庭为基础的药物和解。本研究的具体目的是：1）使用定性和定量方法观察和记录家庭健康药物协调过程中的变化。我将观察最近出院的老年退伍军人完成药物核对的步骤，以记录当前实践的变化。 2)根据相关医疗保健提供者的意见，制定药物核对方案，以识别、优先排序、沟通和解决 及时解决出院用药问题。焦点小组将告知协议的制定，以帮助家庭保健护士优先考虑哪些药物差异在临床上最重要，并塑造沟通工具，以标准化如何将药物差异传达给医生。 3)评价核对方案和沟通工具在缩短解决出院后用药差异的时间方面的可行性、可接受性和有效性。这一试点将为更大规模、资金更充足的干预措施有效性研究奠定基础。 培训计划和指导研究活动将实现以下目标：a）提高我的方法技能（定性和定量）通过教学培训和体验学习; B）通过一系列教育经验，以及参加期刊俱乐部和研究会议，获得实施科学和老年医学方面的额外专业知识;以及c）在跨学科团队的指导下，开发、实施和评估改善出院后用药安全的工具。所有的奖项活动将在一个充满活力和支持性的科学环境中进行，该环境以VA老年医学研究和教育临床中心（GRECC）为基础。总之，通过完成这个职业发展奖，我将获得不可或缺的技能和经验，适用于进行未来的转化研究，提高老年退伍军人的用药安全性，从而可能减少再入院。

DESCRIPTION (provided by applicant): Medication discrepancies, or differences between what medications patients think they should be taking and the regimen collectively ordered by their healthcare providers, affect up to 70% of patients following hospital discharge. Older Veterans are particularly at risk, owing to multiple comorbidities and complex medication regimens. Frequently there are delays in resolving medication discrepancies, which are major contributors to adverse drug events (ADEs). Among older Veterans 33% experience an ADE in the first few months after hospital discharge, substantially increasing their risk of hospital readmission. Medication reconciliation, the proces of identifying the most accurate list of medications a patient should be taking, is an important strategy to reduce potentially harmful medication discrepancies, thereby improving medication safety. After hospital discharge, home health nurses are well-positioned to perform medication reconciliation; indeed, they are required to document discrepancies and alert the treating physicians. Though more older Veterans are utilizing home health services each year, little is known about the process and effectiveness of resolving medication discrepancies in the home healthcare setting. Currently, there is no standardized approach for home health nurses to identify, prioritize, and communicate discrepancies to the treating physician(s). Furthermore, prolonged time to resolution of discrepancies places older Veterans at increased potential harm due to medications. Therefore, tools to improve medication reconciliation are needed. My long-term career goal is to be an independent investigator whose discoveries improve the processes and outcomes of care transitions for older Veterans. This career development award will allow me to gain greater expertise in hospital discharge transitions and medication reconciliation, advance the methodology in measuring discrepancies, and design and test a pilot intervention to enhance home-based medication reconciliation. The specific aims of the research are to: 1) Observe and document variation in the process of home health medication reconciliation using both qualitative and quantitative methods. I will observe the steps to complete medication reconciliation for older Veterans recently discharged from the hospital in order to document the variation in current practice. 2) With input from relevant health care providers, develop a medication reconciliation protocol for identifying, prioritizing, communicating, and resolving post discharge medication discrepancies in a timely manner. Focus groups will inform development of a protocol to help home health nurses prioritize which medication discrepancies are most clinically important and shape the communication tool to standardize how medication discrepancies are communicated to physicians. 3) Evaluate the feasibility, acceptability, and effectiveness of the reconciliation protocol and communication tool on reducing the time to resolution of post-discharge medication discrepancies. This pilot will set the stage for a larger, more robustly funded study of the intervention's effectiveness. The training program and mentored research activities will achieve the following objectives: a) advance my methodological skills (both qualitative and quantitative) through didactic training and experientia learning; b) gain additional expertise in implementation science and geriatrics through a series of educational experiences, as well as participating in journal clubs and research meetings; and c) develop, implement, and evaluate tools to improve medication safety after hospital discharge with guidance from an interdisciplinary team. All of the award activities will take place in a vibrant and supportive scientific environment grounded in the VA Geriatrics Research and Education Clinical Center (GRECC). In summary, by completing this career development award I will acquire indispensable skills and experience applicable to conducting future translational studies that improve medication safety for older Veterans, thereby possibly reducing hospital readmissions.