Frontline Pharmacist

F rontline Pharmacist
Medication reconciliation to facilitate
transitions of care after hospitalization

t is estimated that 20% of patients experience adverse events during the two
weeks after hospital discharge, and over
half of these events
are judged preventable or ameliorable.1
Inadequate medication reconciliation to
identify and resolve
medication-related
problems is believed
to account for 46%
of all medication errors, with 20% of
those errors resulting
in harm.2 Seniors with
complex medication
regimens, cognitive
impairment, or low
health literacy are at
particularly high risk
for medication-related
problems resulting from poorly reconciled medication information at the
transitions of care from the hospital to
the home setting.3
Background. The Rosa Parks Wellness
Institute for Senior Health (RP-WISH)
is a multidisciplinary geriatrics practice,
providing comprehensive primary care
and specialist care and serving as a onestop shop for adults 60 years of age or
older. The multidisciplinary team of providers includes geriatricians, nurses, nurse

practitioners, physician specialists, geriatrics fellows, social workers, psychologists,

and pharmacists. Since 2006, an ambula-

tory care clinical pharmacy specialist, with

board certification and a shared faculty
appointment, has been practicing in
RP-WISH with the purpose of enhancing
the effectiveness, safety, and optimal use
of medications in the senior population
and educating pharmacy residents and
students in those areas.
In 2008, the clinical pharmacy specialist developed, and later published,
the collaborative drug therapy management (CDTM) agreement used in the

The Frontline Pharmacist column gives staff pharmacists an opportunity to share

their experiences and pertinent lessons related to day-to-day practice. Topics include workplace
innovations, cooperating with peers, communicating with other professionals, dealing with
management, handling technical issues related to pharmacy practice, and supervising
technicians. Readers are invited to submit manuscripts, ideas, and comments to AJHP, 7272 Wisconsin
Avenue, Bethesda, MD 20814 (301-664-8601 or ajhp@ashp.org).

690

Am J Health-Syst PharmVol 72 May 1, 2015

clinic.4 Under the CDTM agreement, the

clinical pharmacy specialist can provide
drug therapy management services to
patients with certain conditions upon
physician referral; the pharmacist has
authority to start, stop, or modify pharmacotherapy for those conditions. When
the agreement was
initially developed,
RP-WISH physicians
agreed that the scope
of practice and the
responsibilities outlined in the agreement
were aligned with the
pharmacy specialists
training, skills, and
credentials (although
specific training and
credentials are not
mandated within the
agreement). In addition to ongoing clinical pharmacy specialist
involvement, each year
a postgraduate year 2
(PGY2) pharmacy resident completing a
longitudinal rotation at RP-WISH signs
and practices under the CDTM agreement. Other pharmacy trainees (postgraduate year 1 [PGY1] pharmacy residents and students) rotate through the
clinic and are precepted during activities
outlined in the CDTM.
RP-WISH is designated as a patientcentered medical home by both the Blue
Cross and Blue Shield system and URAC
(formerly known as the Utilization
Review Accreditation Commission),
a nonprofit organization promoting
healthcare quality. The clinic is located
in an urban academic medical center
within Detroit Medical Center (DMC)
and serves as a training site for healthcare students, residents, and fellows.
Additionally, DMC formed an accountable care organization (ACO) in efforts

Frontline Pharmacist

to provide quality care at controlled

costs. Approximately 20% of RP-WISH
patients are part of the ACO.
Considering rising healthcare costs,
safety concerns, and the vulnerability of
a senior population, RP-WISH identified
a need to better coordinate transitions of
care for its patients. Prior to the project
described here, there had not been a
formalized transitions-of-care process in place. Thus, a multidisciplinary
transitions-of-care team comprising
inpatient and outpatient nurses, clinicbased nurse practitioners, pharmacists,
primary care physicians, inpatient and
outpatient social workers, medical assistants, and clerical staff was formed. The
team focused on improving the safety
and continuity of care after any hospital
encounter through increased efforts to
schedule a follow-up primary care appointment within one week of discharge.
Medication reconciliation and safety at
transitions of care was a specific priority of the team; previously, neither the
RP-WISH clinical pharmacy specialist
nor inpatient pharmacists were directly
involved with transitions-of-care medication reconciliation. The RP-WISH
office manager requested that the clinical
pharmacy specialist assist with medication reconciliation through the launch
of a transitions-of-care team. Therefore,
a process for postdischarge medication
reconciliation phone calls was developed
for use by pharmacy students, residents,
and the clinical pharmacy specialist in
contacting patients prior to their followup primary care appointment.
Program design and implementation. The goal of our postdischarge
medication reconciliation service was
to facilitate care transitions with regard
to medications by reconciling patients
home medication use with primary care
and hospital records after a hospital encounter. Calls were targeted at patients
being discharged to home from (1) the
emergency department, (2) an outpatient observation stay, or (3) an inpatient
hospital stay. Accordingly, patients discharged to facilities with responsibility
for medication management (e.g., nursing homes, assisted living facilities, re-

habilitation facilities) were not targeted

for medication reconciliation phone
calls. Using the CDTM agreement,
the pharmacist or trainees identified medication-related problems and
intervened to resolve problems in order
to prevent adverse drug events. As appropriate, the pharmacist provided prescriptions and stopped or modified drug
therapy for identified medication-related
problems during the transitions of care.
During early program development,
it was decided that a streamlined communication process for the transitionsof-care team was essential. Therefore,
an electronic database was created to
house information and communications regarding transitions of care. Also,
weekly team meetings were established
to discuss transitions-of-care issues as
well as overall process improvement.
To educate all clinic staff on the new
program and the medication reconciliation process, pharmacy students on
advanced pharmacy practice experience
(APPE) rotations developed inservices.
The students also created a transitionsof-care training manual that now serves
as required reading for all students and
residents rotating through RP-WISH.
In March 2012, the clinical pharmacy
specialist and the PGY2 ambulatory care
pharmacy resident initiated the postdischarge medication reconciliation phone
calls. Soon after, pharmacy students and
PGY1 pharmacy residents on rotation
began conducting the calls.
Trainees on rotation are an important resource to the program. In addition to reading the training manual,
trainees receive oral orientation to the
process and conduct their initial calls
under the clinical pharmacy specialists
supervision until competency is demonstrated. Finally, they must present their
findings from review of the electronic
medical record (EMR) to the pharmacist before calling the patient in any
case involving one or more high-risk
medications, including anticoagulants,
insulin, antiepileptics, opioids, immunosuppressants, and chemotherapy.
Program description. Daily responsibilities are divided among the clinical

pharmacy specialist, the PGY2 resident,

and other trainees such that there is coverage by designated team members each
day. The transitions-of-care database is
updated daily by the team nurse who
receives notification of admissions and
discharges from within our health system
(and many from other health systems as
well). The database is assessed daily by
the pharmacy staff to identify patients
discharged home who are eligible to receive medication reconciliation services;
at least three attempts to call a patient are
made in the time between discharge and
the scheduled primary care follow-up
visit. Each attempted call is documented
in the database. Once the patient is contacted, documentation of the medication
reconciliation call is made in the EMR,
and the electronic medication list is
updated.
To support ambulatory care pharmacists within the clinic, new or enhanced
EMR funtionalities were established.
The increased EMR functionalities
included electronic creation of phone
encounter records, authorization to
perform the medication reconciliation
function (previously available only to
physicians and midlevel providers),
access to external prescription fill history, the ability to create customized
patient-specific education materials,
and the ability to prescribe medication
electronically to outpatient pharmacies.
Furthermore, pharmacy students were
also granted enhanced EMR access, enabling them to create phone encounter
records and update a patients pharmacy
information. Pharmacy trainees can
document progress notes and patient
education in the EMR; their notes can
be electronically forwarded to the clinical pharmacy specialist, who can then
edit and cosign the documents within
the EMR.
In the early phases of program
implementation, RP-WISH entered into
a data use agreement with Michigans
Healthcare Quality Improvement
Organization, an agent of the Centers for
Medicare and Medicaid Services (CMS).
Under this agreement, we were able to
study the impact of the program on

Am J Health-Syst PharmVol 72 May 1, 2015

691

Frontline Pharmacist

healthcare services utilization by evaluating patient claims data from within and
outside of the medical center.
Preliminary data. From March 1
through October 31, 2012, there were
638 index discharge events, of which 83%
(n = 527) involved patients eligible for
postdischarge medication reconciliation.
Attempts were made to call 178 patients
(34.0% of those eligible), and medication reconciliation was completed for
93 patients (52.2% of those attempted).
Despite multiple phone calls at varying
times of day, 56.4% of the attempted calls
elicited no answer and another 16.5%
failed due to inaccurate phone numbers,
highlighting noteworthy patient communication barriers.
Retrospective records reviews were
conducted to describe and assess patient
safety findings associated with the medication reconciliation phone calls. On average, 31 minutes (S.D., 13 minutes) was
spent on each call. Polypharmacy was a
finding common to most calls; contacted
patients reported taking a mean S.D.
of 10 4 medications. A considerable
percentage of the calls (59.2%, n = 55)
were completed by the pharmacy trainees, highlighting the important role they
can play in the medication reconciliation process. A total of 288 medicationrelated problems were identified (mean
S.D., 3 2 per call). Most of the patients
(81.7%) had at least 1 medication-related
problem identified during a call. The
most serious problems involved highrisk medications, concomitant use of
contraindicated medications, or medications related to the primary diagnosis
of the index discharge event that were
deemed likely to place the patient at high
risk for requiring healthcare intervention. Resolution of medication-related
problems by the transitions-of-care team
was judged to have potentially averted
healthcare intervention or hospitalization in 10% of cases.
In order to evaluate the impact of the
postdischarge medication reconciliation phone calls, claims data are used to
evaluate 30-day readmission rates as well
as hospital utilization rates. Data collection and analysis are ongoing.

692

Changes in pharmacy practice and

training. The RP-WISH transitions-ofcare program was the first within the
medical center and provided a model for
a subsequent pharmacy practice realignment within the inpatient pharmacy department of DMC. In May 2012, DMC
chose to participate in the Medicare
Shared Savings Program,5 implemented by CMS pursuant to the Patient
Protection and Affordable Care Act, by
establishing the medical centers ACO.
The executive medical director of the
ACO approached the clinical pharmacy
specialist at RP-WISH to discuss a proposed expansion of the postdischarge
transitions-of-care program to include
ACO patients. As a result of these initial
meetings, the pharmacy department
and the ACO formed a collaborative
transitions-of-care team using the
RP-WISH teams postdischarge medication reconciliation model and documentation process. Consequently, the
DMC inpatient pharmacy practice
model was expanded and new patient
care opportunities were created for
pharmacists. This new model incorporated medication history-taking during
a hospital stay and medication reconciliation after hospitalization in order to
facilitate safe care transitions. Education
was provided for all pharmacy staff via
continuing-education presentations,
staff meetings, and written manuals.
There was some initial resistance to the
change in responsibilities; however, this
was overcome in time through ongoing education about the importance of
medication reconciliation and consistent emphasis by management. In addition, two pharmacist positions were
redefined and realigned to emphasize
medication reconciliation and counseling: one was dedicated to serving ACO
patients being discharged from inpatient services, and the other was aligned
to provide transitions-of-care services
to patients discharged from DMCs 24hour observation unit.
Also, the inpatient practice model
realignment transformed the role of
pharmacy technicians, giving them responsibilities for supporting medication

Am J Health-Syst PharmVol 72 May 1, 2015

reconciliation by calling outpatient pharmacies to update incomplete home medication profiles. The technicians assuming these responsibilities were trained by
the clinical pharmacy specialists.
The practice model realignment also
created a new APPE rotation, under the
preceptorship of the observation unit
clinical pharmacy specialist, emphasizing
medication reconciliation.
The implementation of the transitionsof-care program in RP-WISH and
subsequent inpatient practice model
realignment have provided new and
distinctly different patient care opportunities for both pharmacy students and
residents throughout the health system.
At the same time, the health system has
benefited, as trainees provide a valuable
resource by increasing the systems ability to reach more patients. The numbers
of students and residents precepted in
RP-WISH have doubled as a result of
the transitions-of-care program, and the
new APPE rotation provides inpatient
resources that were once not available.
Within the RP-WISH program, trainees have often conducted a medication
reconciliation phone call with a patient and then participated in the same
patients postdischarge primary care
visit. Furthermore, working under the
CDTM agreement, trainees were able to
experience firsthand the great influence
a pharmacist can have in optimizing
patient care by implementing medication changes rather than simply making
recommendations.
Challenges and future directions.
The RP-WISH transitions-of-care program has fostered multidisciplinary
teamwork to improve patient care by
minimizing medication-related problems.
Prior to the launch of the program, a lack
of coordinated communication by team
members was the greatest challenge. This
challenge was overcome by the development of an electronic database housed in
a centralized location that can be accessed
by all members of the team.
Challenges in reaching patients by
phone to conduct medication reconciliation continue to exist. The success rates for
attempted and completed phone contacts

Frontline Pharmacist

with patients are influenced by factors

such as disconnection of phone service,
inaccurate phone numbers, and limited
availability of pharmacy personnel to conduct calls. It takes time to orient trainees
to the transitions-of-care program and
the process for conducting medication
reconciliation phone calls, and this lowers the rate of success in reaching patients
during the orientation phase of experiential training. Increased patient contact
rates might have the potential to improve
patient outcomes to a greater extent than
has been achieved to date.
Currently, patients discharged to
subacute rehabilitation facilities do
not receive medication reconciliation phone calls, as those facilities are
responsible for managing patients
medications. Such discharges carry the
potential for medication-related problems to occur; however, communication between RP-WISH and rehabilitation facilities outside the DMC system
is not always consistent. Therefore,
future directions include developing
an enhanced system for monitoring
and transitioning these patients to the
primary care clinic.
The electronic database used to
communicate information among team
members requires considerable data

entry time. To streamline workflow and

increase the time spent by transitions-ofcare team members in providing direct
patient care, future directions include the
pharmacy informatics team building an
autopopulating electronic database that
interfaces with the health systems EMR.
Included in the automated electronic
database are plans for a system to remind
team members to follow up on discharge
plans and transitions-of-care needs for
patients admitted to subacute rehabilitation facilities.
1. Forster AJ, Murff HJ, Peterson JF et al. The
incidence and severity of adverse events
affecting patients after discharge from the
hospital. Ann Intern Med. 2003; 138:161-7.
2. Barnsteiner JH. Medication reconciliation:
transfer of medication information across
settingskeeping it free from error. Am J
Nurs. 2005; 105:31-6.
3. Agency for Healthcare Research and Quality. Health literacy universal precautions
toolkit. 2010. www.ahrq.gov/qual/literacy/
healthliteracytoolkit.pdf (accessed 2014
Feb 25).
4. Garwood CL, OConnell MB. Collaborative drug therapy management: pharmacotherapy clinic. In: Westberg SM, Currie
JD, Garwood CL et al., eds. Ambulatory
care pharmacists survival guide. 3rd ed.
Lanexa, KS: American College of Clinical
Pharmacy; 2013:378-82.
5. Centers for Medicare and Medicaid Services.
Statutory basis for the Shared Savings Program. www.cms.gov/Medicare/MedicareFee-for-Service-Payment/SharedSavings

Program/Statutes_Regulations_Guidance.
html (accessed 2015 Feb 15).

Victoria C. Liu, Pharm.D., Ambulatory

Care Clinical Pharmacy Specialist
Boston Medical Center
Boston, MA
Candice L. Garwood, Pharm.D., FCCP,
BCPS, Clinical Associate Professor,
Department of Pharmacy Practice
Eugene Applebaum College of Pharmacy
and Health Sciences
Wayne State University
Detroit, MI
Ambulatory Care Clinical Pharmacy
Specialist, Department of Pharmacy
Harper University Hospital and Rosa Parks
Wellness Institute for Senior Health
Detroit Receiving Hospital
Detroit Medical Center
Detroit, MI
cgarwood@wayne.edu

At the time of project implementation, Dr. Liu was Postgraduate Year 2

Ambulatory Care Pharmacy Resident,
Harper University Hospital, Detroit
Medical Center, Detroit, MI.
The authors have declared no potential
conflicts of interest.
DOI 10.2146/ajhp140133

Am J Health-Syst PharmVol 72 May 1, 2015

693