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.