Navigating Transitions in Care: Why Medication Reconciliation Matters

Understanding Transitions in Care

When you hear the phrase "transitions in care," what comes to mind? You might think of a patient leaving a hospital to go home, leaving a long-term care facility for a hospital stay, or moving from one post-acute care facility to another. In healthcare, the official definition according to the Centers for Medicare and Medicaid Services (CMS) is "the movement of a patient from one setting of care (hospital, ambulatory care practice, long-term care, home health, home) to another."

Moving from one care setting to another is much more than a clinical process. For many patients, transitions of care are stressful and perplexing for both them and their loved ones. Familiar routines are disrupted, and patients must adapt to new caregivers and surroundings. Even essential tasks such as activities of daily living (ADLs) are carried out differently, which can increase feelings of vulnerability. In the study "Trajectories Over the First Year of Long-Term Care Nursing Home Residence," Li et al. (2017) examined over 580,000 Medicare beneficiaries and found that patients experienced an average of 2.1 care transitions in their first year. These transitions underscore the critical importance of seamless communication and coordination, as the safety and well-being of individuals depend on the accurate transfer of information. While these movements are often a necessary part of a patient's healthcare journey, the complexity involved in ensuring continuity of care is frequently underestimated.

One of the most essential yet often overlooked elements of a safe and effective care transition is medication reconciliation. This process involves verifying and updating a patient's complete medication list to ensure accuracy as they move from one care setting to another. This could be from a hospital to long-term care, home to rehabilitation, or any point in between. Medication reconciliation should occur at every transition, simple or complex, to prevent discrepancies that can lead to adverse drug events, rehospitalizations, or worse. It requires coordination between primary and referring providers, pharmacists, and often the patient and/or caregiver, to align current medications with the individual's evolving clinical status. When done properly, medication reconciliation not only preserves continuity of care but also protects patients during difficult phases in their healthcare journey.

The reality is that every transfer of care increases the potential for breakdowns in communication and medication discrepancies, resulting in potentially serious consequences and patient harm.

Medication Reconciliation: Impact on Long-Term Care Patients

• Approximately 70% of long-term care (LTC) admissions involve at least one medication discrepancy, highlighting the critical need for accurate medication reconciliation during transitions of care (Tam et al., 2005).

• Over 21% of medication errors occur during transitions between hospitals and long-term care (LTC) facilities, emphasizing how vulnerable patients are during these handoffs and the critical role of medication reconciliation (Tjia et al., 2009).

• Up to 60% of medication discrepancies are classified as serious, life-threatening, or even fatal, underscoring the high-risk nature of transitions in care and the critical need for thorough medication reconciliation (Boockvar et al., 2004).

In long-term care settings like skilled nursing facilities and assisted living communities, transitions of care are a routine part of daily clinical operations. Patients in these settings often live with multiple chronic conditions and require complex medication regimens to manage comorbidities, leading to polypharmacy concerns. Medication reconciliation is essential to ensure accuracy and safety, but frequent handoffs, multiple prescribers, and inconsistent records make the process challenging. While advances in healthcare technology have improved how we share information, they can also create a false sense of accuracy and security, and lead to errors.

Nurses and pharmacists play a critical role in catching these errors-whether they occur in hospitals, skilled nursing facilities, or other care settings. One of the most effective ways to reduce medication-related harm is by conducting a thorough medication reconciliation at every transition of care.

Leveraging Pharmacy Expertise to Strengthen Medication Reconciliation

At Remedi SeniorCare and ProCare, LTC pharmacy divisions of Clarest Health, our consultant pharmacists have decades of pharmacy expertise and serve as clinical partners to facilities caring for patients with complex medication management needs. With deep experience across thousands of transitions of care, our pharmacists support facilities through critical moments such as admissions, discharges, and ongoing medication regimen reviews (MRRs). They work alongside care teams to identify risks, resolve discrepancies, and support clinical appropriateness for medication regimens, ensuring orders align with the resident's current needs. Drawing from this frontline experience, our consultant pharmacists have identified five commonly overlooked assumptions in the medication reconciliation process. The following insights reflect real-world challenges that often arise during transitions of care and provide actionable strategies to help strengthen the medication reconciliation practices.

Five "Don't Assumes" in Long-Term Care Medication Reconciliation

1. Don't assume medication reconciliation was done accurately in another care setting.

In acute care environments, the immediate focus is often on the urgent condition, which can mean simply "continuing" or "holding" other medications without fully reviewing them. Sending a long, unorganized list of medications to the next provider can be overwhelming and lead to "reconciliation fatigue," the tendency to accept prior documentation at face value due to the overwhelming volume of information or time constraints. This increases the risk of duplications, omissions, and potentially inappropriate therapies being carried forward.

Tip: Provide a concise, accurate list to support safe, effective care.

Even if a prior healthcare facility completed a reconciliation, do not assume it was comprehensive or correct. Always begin with a concise, verified medication list that includes dose, route, frequency, and indication and cross-check it against current diagnoses, lab values, and clinical status. When possible, prioritize communication with the discharging facility to clarify any discrepancies or unusual orders.

By ensuring the list you receive is accurate and manageable, you reduce confusion for your staff and help ensure safe, clinically appropriate care for the resident from day one.

1. Don't assume another facility's electronic health record (EHR) list is correct.

While electronic health records (EHRs) have improved access to documentation, they're only as reliable as the data entered. Medication lists are particularly susceptible to errors during transitions of care.

Hospital EHRs may keep an "at-home" medication list for inpatients that reflect what they were taking prior to admission, but these lists are often based on incomplete information from the patient, a family member, or prior records. As the inpatient team focuses on treating the acute condition, these medications may not be reviewed in detail. Additionally, medications that were discontinued, adjusted, or substituted during the hospital stay may remain on the list without proper annotation.

These outdated or inaccurate entries can easily carry over into discharge instructions, where they may be interpreted by the receiving skilled nursing facility as current, verified orders. This creates serious safety risks, including therapeutic duplications, missed deprescribing opportunities, incorrect dosages, and medications no longer clinically indicated.

Tip: Always verify the medication list before using it as a baseline beginning with reviewing each medication against the resident's current clinical status, labs, and recommended treatment plans. Confirm the accuracy of medication names, dosages, routes, and frequencies, and watch for inconsistencies or unusual combinations. Engage the resident, family members, your facility's consultant pharmacist, or prior prescribers when clarification is needed, and look beyond the discharge paperwork to locate the most accurate medication history.

By verifying the list, your team can prevent the negative impact of inaccurate records and better support safe, personalized care from the start.

1. Don't assume EHR systems communicate with each other.

Even if two health systems use the same EHR platform they often operate in separate environments that do not share real-time data. This means medication lists can differ significantly between a resident's primary care provider, specialists, and hospital stays. medication lists can vary between primary care providers, specialists, and hospitals.

For example, a cardiologist might prescribe a medication that is not visible to the primary care team, or a drug discontinued during hospitalization might still appear on the outpatient record. In some cases, medications that are unrelated to the immediate medical concern may not be reviewed at all during a hospital stay. As a result, outdated, missing, or conflicting information can easily pass through the system unnoticed.

Tip: Verify the medication list across multiple sources rather than relying on assumed connectivity. Cross-check with recent discharge summaries, pharmacy fill histories, previous provider records, and direct communication with the resident or caregiver when possible. Taking a few extra steps to reconcile across systems ensures a more complete picture and helps prevent avoidable medication errors during transitions.

1. Don't assume residents and caregivers know what's on the medication list.

It's often assumed that medication lists are complete and accurate, especially when a resident or their caregiver provides verbal confirmation. However, comfort levels with managing medication lists vary widely among individuals. Some residents may find it difficult to recall exact medication names, dosages, or administration times. Others may be unaware of recent changes, particularly if they were made during a hospital stay or by a specialist they see infrequently. Over-the-counter drugs and supplements may be missing entirely, causing potential interactions to occur when taken with prescribed medications. Even when a resident requests updates, changes may not happen if the drug wasn't originally prescribed by the provider.

Tip: Whenever possible, involve residents and families in the medication reconciliation process, giving them the opportunity to review the medication list. Sit down with them to review each item on the list, go beyond a yes-or-no approach to confirm what is actually being taken, and clarify any concerns or discrepancies. Using open-ended and guided questions can help uncover missing details. This extra effort often reveals valuable insights and helps ensure the list reflects what the resident is taking.

1. Don't assume the previous facility's list is complete and accurate.

Even when a discharge medication list appears comprehensive, it can contain critical errors or omissions. Without careful review, these issues may carry over into the new care setting and compromise resident safety. Potential discrepancies include the following:

• Differences in dose or frequency from the resident's pre-admission list
  Medications may be restarted at the wrong strength or frequency due to miscommunication or oversight. For example, a resident who was previously on a blood pressure medication once daily may now be listed as taking it twice daily, potentially leading to hypotension or other adverse effects. Comparing the discharge list with pre-admission records helps identify unintended changes.

• Changes in medication form, such as extended-release versus immediate-release
  A hospital may substitute an immediate-release formulation for cost or availability reasons, but this change is not always communicated clearly on discharge. If the extended-release version is not reinstated when appropriate, it can affect drug absorption, timing, and symptom control. Identifying and correcting formulation mismatches ensures continuity and therapy effectiveness.

• Missing stop dates for antibiotics or anticoagulants
  Short-term therapies are often prescribed with an intended duration, but this is not always documented in the discharge instructions. Without a stop date, staff may continue administering these medications, increasing the risk of complications such as bleeding, infection resistance, or adverse drug reactions. Always confirm whether a medication is intended to be ongoing or temporary.

• Psychotropics started for non-psychiatric reasons during hospitalization
  Patients may be started on antipsychotics, benzodiazepines, or sedative-hypnotics during a hospital stay to manage agitation, sleep disturbances, or behavioral symptoms. These medications are sometimes continued upon discharge even if the original issue has resolved. Without a clear diagnosis or clinical justification, these drugs can pose unnecessary risks and dependency, especially in older adults.

Tip: When possible, review the discharge medication list with the discharging facility before the patient arrives. Request that they send the list in advance so you can go through it together. If the resident is being readmitted, compare the new list to their prior medication history to identify any discrepancies or changes. After completing this review, upload the finalized list to your facility's electronic health record. This ensures that your consultant pharmacist has timely access to conduct a second, thorough review for clinical accuracy and safety.

Partnering to Improve Medication Reconciliation During Care Transitions

Every transition in care is more than a physical and logistical shift. It is a crucial moment to help protect a patient's health and well-being. Accurate medication reconciliation is not just a compliance task; it serves as a frontline defense against preventable harm and an important factor in medication adherence.

Understanding the role of medication safety, compliance, and reconciliation is a key element in successfully navigating care transitions. When nurses move beyond assumptions to carefully verify, clarify, and communicate medication information, they significantly reduce errors and promote safer transitions. These actions ultimately improve patient outcomes and enhance quality of life.

Discover how our comprehensive long-term care pharmacy services and consultant pharmacist clinical expertise can support your skilled nursing facility: www.remedirx.com.