There is a well-known association between transitions of care and medication-related problems, notably in the form of adverse drug events. Although we have limited evidence-based information on this topic in assisted living facilities (ALFs), some of what we’ve learned from transitions of older adults to nursing homes provides useful insight into what we can expect. In a study looking at the bidirectional transfer of individuals leaving a skilled nursing facility (SNF) to go to the hospital and then coming back to the same SNF, researchers found that medications were changed that should not have been and doses were changed inappropriately (Arch Intern Med 2004;164:545–550). Also, because the hospital formularies were different, medications were substituted, resulting in duplication of medication classes. Twenty percent of these changes resulted in adverse drug events. A study that followed up with older adults in their homes after a hospitalization found that the discharge instructions from the hospital were often incomplete or illegible, the information conflicted between different sources, and duplicative prescribing occurred because of therapeutic interchange during hospitalization (Arch Intern Med 2005;165:1842–1847). Of those for whom a medication discrepancy was identified (n = 53), 14.3% were rehospitalized within 30 days compared with the 6% who had no medication discrepancies noted (n = 322, P = 0.04).ResourcesSome useful tools to help ensure safe transitions for ALF residents are available from:•The Care Transitions Program: https://caretransitions.org. The Personal Health Record can help the resident and family caregiver organize important health information that may not readily be available in the ALF’s health record.•The National Transitions of Care Coalition: http://www.ntocc.org. The “My Medicine List” allows residents to record how medications are being taken, which informs the health care team and family caregiver of how medications are being taken in support of patient-centered care. Some useful tools to help ensure safe transitions for ALF residents are available from:•The Care Transitions Program: https://caretransitions.org. The Personal Health Record can help the resident and family caregiver organize important health information that may not readily be available in the ALF’s health record.•The National Transitions of Care Coalition: http://www.ntocc.org. The “My Medicine List” allows residents to record how medications are being taken, which informs the health care team and family caregiver of how medications are being taken in support of patient-centered care. In 2014, the Office of the Inspector General reported on adverse events in 653 Medicare beneficiaries who were hospitalized and subsequently discharged to SNFs (“Adverse Events in Skilled Nursing Facilities,” Feb. 2014; http://bit.ly/2lPjGeu). This transition in care resulted in an adverse event in 22% of individuals. Of these adverse events, 37% were medication related, with 11% resulting in harm to the patient. A team of physicians, including a nursing home medical director, evaluated each event and determined that 59% were preventable. This remains one of the largest studies conducted on adverse events and medication-related harm during transitions of care and nursing home residents, and the results have had an effect on policies. Digging deeper into the issue of adverse drug events in older adults, especially those who are the typical age of ALF and nursing home residents (80+ years and older on average), reveals some useful information on the targeted efforts to reduce these harmful events. In a Centers for Disease Control and Prevention (CDC) report examining adverse drug events that have contributed to an emergency department (ED) visit and often a subsequent hospital admission, five classes of medications contributed to more than three-fourths of all adverse events: anticoagulants, diabetes agents, antiplatelets, nonsteroidal anti-inflammatory agents, and opioids (JAMA 2016;316:2115–2125). Like nursing homes residents, individuals living in ALFs take quite a few medications. In a post hoc analysis of clinical trial data collected during an ALF study looking at rehabilitative care, Barbara Resnick, PhD, CRNP, of the University of Maryland School of Nursing and her colleagues noted that 51% of a cohort of 242 individuals, mean age 86 and 74% female, were consuming five or more routine medications (Consult Pharm 2018:33:321–330). Of note, 54% of their study population were taking an anticoagulant. This is consistent with the observed 22% rate of ED visits or hospitalizations observed in this cohort over the 12-month study and the CDC data on adverse drug events. Pharmacists have several roles in the medication-use process in ALFs, including dispensing medications — usually from the same pharmacies that serve nursing homes — and medication regimen review. The dispensing process for most ALFs is remarkably similar to that of nursing homes, including the technology attributes, although ALFs are lagging a little behind SNFs in implementing electronic health records and electronic medication administration records. Physicians and other prescribers can order medications in a similar fashion because the same pharmacies are used. But because the number of licensed health care personnel is often lower in an ALF than in a nursing home, it is important for prescribers to understand the differences.Key PointsFor comprehensive background on medication reconciliation, the MARQUIS program (Multi-Center Medication Reconciliation Quality Improvement Study), funded by the Agency for Healthcare Research and Quality, is one of the most up-to-date and informative guides currently available (Society for Hospital Medicine, “MARQUIS Implementation Manual,” Aug. 2017; www.hospitalmedicine.org/MARQUIS). From this guide and other evidence, here are key points to consider for reducing harm associated with medication discrepancies during transitions of care:•Prioritize your medication regimen review efforts by risk:◦High-risk — higher number of medications, multiple disease conditions, and high-risk medications; anticoagulants (e.g., warfarin, apixaban, and others), antiplatelets (e.g., aspirin and clopidogrel), hypoglycemic agents (e.g., insulin and sulfonylureas), nonsteroidal anti-inflammatory agents (e.g., ibuprofen and naproxen), and opioid analgesics (e.g., oxycodone and morphine).◦Low-risk — routine level review.•Always ensure that the resident and caregiver have an updated medication list and a general understanding of their role in the treatment plan.•Complete a Personal Health Record for each resident whenever possible that can provide the necessary information to others should a transition in care occur when the resident is in a compromised state and the caregiver is not available.•On a resident’s return to the ALF, include the resident and family caregiver in the discussion about what is new regarding medications and how they align (or do not align) with their goals of care.•When the resident is stable, consider evaluating the goals of care and implement deprescribing, when appropriate. Much attention is being given to this issue, with the goal of reducing medication-related complications, improving outcomes, and reducing costs (J Am Coll Cardiol 2019;73:2584–2595). For comprehensive background on medication reconciliation, the MARQUIS program (Multi-Center Medication Reconciliation Quality Improvement Study), funded by the Agency for Healthcare Research and Quality, is one of the most up-to-date and informative guides currently available (Society for Hospital Medicine, “MARQUIS Implementation Manual,” Aug. 2017; www.hospitalmedicine.org/MARQUIS). From this guide and other evidence, here are key points to consider for reducing harm associated with medication discrepancies during transitions of care:•Prioritize your medication regimen review efforts by risk:◦High-risk — higher number of medications, multiple disease conditions, and high-risk medications; anticoagulants (e.g., warfarin, apixaban, and others), antiplatelets (e.g., aspirin and clopidogrel), hypoglycemic agents (e.g., insulin and sulfonylureas), nonsteroidal anti-inflammatory agents (e.g., ibuprofen and naproxen), and opioid analgesics (e.g., oxycodone and morphine).◦Low-risk — routine level review.•Always ensure that the resident and caregiver have an updated medication list and a general understanding of their role in the treatment plan.•Complete a Personal Health Record for each resident whenever possible that can provide the necessary information to others should a transition in care occur when the resident is in a compromised state and the caregiver is not available.•On a resident’s return to the ALF, include the resident and family caregiver in the discussion about what is new regarding medications and how they align (or do not align) with their goals of care.•When the resident is stable, consider evaluating the goals of care and implement deprescribing, when appropriate. Much attention is being given to this issue, with the goal of reducing medication-related complications, improving outcomes, and reducing costs (J Am Coll Cardiol 2019;73:2584–2595). There are opportunities in ALFs for more resident-directed medication administration strategies, including simplifying medication regimens to suit the resident’s daily routine and use of devices such as in-room medication cabinets. Collectively, these approaches can lead to decreased medication administration time while enabling an increased staff presence with the residents (Consult Pharm 2018;33:533–561). Although the medication regimen review process is similar to that provided monthly in nursing homes, and often it is performed by the same consultant pharmacists, the regulations vary by state. Some states mention other health care professionals, including nurses and physicians, as potential reviewers, but pharmacists are the predominant provider who performs the service, and this is specified by three states: California, Kansas, and Maryland (National Center for Assisted Living, “Assisted Living State Regulatory Review,” Mar. 2013; http://bit.ly/2lm5XLV). The frequency of medication reviews in ALFs are typically quarterly, although at least one state requires a monthly review. The reviewing pharmacist and the prescribing clinician should establish how they want to be notified of potential medication issues in order for the process to be efficient and in the resident’s best interest. As in nursing homes, those individuals performing medication regimen reviews should pay particular attention to the residents who have had a transition in care since the last review. Ideally these individuals had a medication reconciliation when they entered the hospital; however, many acute care facilities limit those who qualify for a review based on their rehospitalization risk, so some will not perform this task. Even on a retrospective assessment, some basic guidelines will help identify the medication discrepancies with the greatest potential to cause harm. In the sidebar, I have summarized the key actions to reduce harm associated with medication discrepancies occurring during transitions of care. These, along with the resident-directed medication administration I’ve discussed here, can make a positive difference in your facility. Dr. Davidson is a partner of Insight Therapeutics, a research and patient care consulting firm in Norfolk, VA, and is assistant professor of clinical internal medicine at the Glennan Center for Geriatrics and Gerontology, Eastern Virginia Medical School. He is a current member of the Transitions of Care Committee of AMDA – The Society for Post-Acute and Long-Term Care Medicine and participated in the development of the Transitions of Care in the Long-Term Care Continuum Practice Guideline and White Paper on Dementia and Care Transitions.