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BACKGROUND

Pharmacist involvement in transitional care management activities post-discharge is critical to ensure safe and effective medication therapy outcomes in patients as they move between healthcare settings. Pharmacists in the outpatient setting, including both community and ambulatory care, may be involved prior to discharge in patient care activities such as medication reconciliation prior to discharge, bedside teaching of discharge medications, patient assistance for improving medication access, or prescription delivery services such as “meds-to-beds.” Post-discharge, outpatient pharmacists may conduct follow-up phone calls to patients preferably made within 1 to 3 days once the patient returns home. The purpose of these calls is to reinforce any patient education, ensure the patient has received their medications, check on the clinical status of the patient, and to answer any questions they may have. In addition, this is a good time to ensure the patient has a post-discharge follow-up appointment scheduled with a primary care or specialty physician to ensure continuity of care. The next point of contact differs in purpose and timing based on location.

Community pharmacists often see patients post-discharge before any other healthcare team members. This is because patients and/or caregivers head to the community pharmacy shortly after hospital discharge to pick up prescriptions. This represents a great opportunity for the community pharmacist to perform medication reconciliation with the patient’s discharge prescriptions and the prior-to-admission medication list. If any medication errors or discrepancies are identified, the pharmacist should hold off on dispensing these prescriptions, inform the patient of the situation, and call the prescribing physician to resolve the issue. This patient encounter is also a good time to reinforce patient education on medications, conditions, and self-care. We can also answer any questions or address concerns the patient may have now that they have left the hospital. Community pharmacists often have an established rapport with patients, which may result in the patient feeling at ease to ask questions and follow pharmacist recommendations on medication adherence and self-care.

Ambulatory care pharmacists are able to interact with patients at their post-discharge follow-up appointments that should occur within 1 to 2 weeks based on patient medical complexity. It is important for patients to attend these clinic appointments as this is often where adverse events can be mitigated and ultimately prevent unplanned emergency department visits or hospitalizations. At the clinic, pharmacists may be involved in the following transitions of care activities: post-discharge phone calls or communication, review of discharge information, medication reconciliation, follow-up on pending labs or diagnostic tests, optimization of medication therapy, providing patient education, and addressing patient-specific needs or barriers to care.

Medication reconciliation should occur at every transition of care for a patient. At the clinic setting, it can be helpful to have patients bring in their medication bottles, their medication list, and conduct a ...

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