Evaluation of Pharmacist-Initiated Discharge Medication Reconciliation and Patient Counseling Procedures.

OBJECTIVE

To evaluate a recently implemented procedure of discharge medication reconciliation and patient counseling completed by pharmacists at a nursing facility.

SETTING

This is a 138-bed nursing facility that houses long-term care residents as well as patients for subacute rehabilitation.

PRACTICE DESCRIPTION

Discharge process involves the medical team (geriatrician, medical resident, medical students), social workers, and nurse coordinators.

PRACTICE INNOVATION

Pharmacists are incorporated in the discharge process by completing medication reconciliation, patient counseling, and telephone follow-up, to improve patient understanding and satisfaction.

MAIN OUTCOME MEASUREMENTS

Medication discrepancies identified by pharmacists via medication reconciliation, number of patients who were counseled by pharmacist, and number of patients encountered for telephone follow-up.

RESULTS

Fifty-four patients were discharged during the study period. A total of 200 discrepancies were identified after discharge medication reconciliation by the pharmacist. On average, we found that there were 4 discrepancies per patient (range 0 to 16). Most of the discrepancies that were found were medication additions and omissions. Forty-five patients (83.3%) agreed to counseling and were then counseled by a pharmacist. Patients were often not counseled because of last-minute discharge, and no encounter was made.

CONCLUSION

Involving pharmacists in patient transitions of care may be beneficial as previous studies have demonstrated; however, additional studies in a nursing facility setting are needed to validate these benefits.