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Discharge Counseling Activity

When a patient is discharged from an institutional setting (eg, hospital) back into an outpatient (ambulatory) setting, it is very common for the discharging provider to modify medications and/or prescribe medication(s) that the patient was not taking prior to admission. In such cases, patients require education on new medication regimens and/or new medications just as they would from an outpatient provider. Many hospitals look to pharmacists to provide high-quality medication education at, or just before, the time of discharge. This clinical service is usually referred to as “discharge counseling.”

Counseling a patient on a new medication regimen or new medication in the institutional setting is similar to a community pharmacy setting. You will use many of the same communication skills and cover very similar information. However, there are a few small differences to consider in order to ensure you are approaching the encounter appropriately:

  • Your instructions, explanations, and counseling points should reflect the fact that your encounter is taking place at the “bedside” (ie, within the patient’s room) within a hospital. For example, a pharmacist providing discharge counseling services often does not have the physical medication product available at the time of counseling (although some hospitals do utilize a program that dispenses medications to patients before they leave the hospital, often referred to as a “Meds to Beds” service).

  • By the time of discharge, a complete and accurate medication reconciliation should have already taken place upon the patient’s admission to the hospital. For this reason, you generally will not need to spend a significant amount of time reviewing the patient’s unchanged “home” medications when providing discharge counseling. You should, however, consider the possibility of interactions or adverse effects that may result from any changes in the patient’s medication regimen or health status; such concerns may well be pertinent to discuss with the patient. You should still verify the patient’s drug allergies (and reactions) since the patient is getting a new medication.

  • To provide the patient with a method for follow-up in case of additional questions, you may encourage the patient to utilize her/his community pharmacist as a resource for more information. In practice, some hospital pharmacists may invite the patient to call the hospital pharmacy with any questions (but logistically, this can often be difficult in the institutional setting). Other hospitals may connect the patient with a “discharge coordinator” (the position title may vary by institution) who can act as a “point person” and link to resources for patients experiencing issues during or after discharge.

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