Impact of community pharmacist-performed post-discharge medication reviews in transitions of care.

OBJECTIVES: To describe a community pharmacist-led transitions of care process for patients discharged from the inpatient to the outpatient setting.

SETTING: Independent community pharmacy chain in northwestern and central Missouri and a rural nonprofit hospital in Marshall, Missouri.

PRACTICE DESCRIPTION AND INNOVATION: This innovative transitions of care service model relies on the inpatient pharmacy team for recruitment and referral of patients who use Red Cross Pharmacy. On discharge, patient information was transmitted to Red Cross Pharmacy via direct messaging in the form of a continuity of care document. Pharmacists used the patients' continuity of care documents to perform telephone-based medication reconciliations and comprehensive medication reviews. Drug-related problems and pharmacists' recommendations were documented in a subjective, objective, assessment, and plan (SOAP) note that was transmitted to the hospital and primary care provider.

EVALUATION: The number and type of drug-related problems and pharmacists' recommendations were assessed with the use of descriptive statistics. Pharmacists' time spent was tracked, and its relationship to alternate variables was assessed with the use of bivariate correlations.

RESULTS: Pharmacists identified 69 drug-related problems and made 145 recommendations for the 35 patients meeting study criteria. The mean time for total service completion was 65 minutes and positively correlated with a number of variables, including identification of the drug-related problem and unnecessary drug therapy and recommendation to decrease the dosage of a medication.

CONCLUSION: Community pharmacists have the ability to identify drug-related problems and make recommendations for patients moving from the inpatient to an outpatient setting. In addition, the data suggest that when given adequate time, pharmacists performing service responsibilities may identify more drug-related problems, resulting in additional recommendations.