Review of a pharmacist discharge medication reconciliation program: characterization of medication discrepancies and prescriber follow up in patients with and without recent hospital admission Brittany Reynolds, PharmD Candidate, Trista Pfeiffenberger PharmD, Monique Alford, PharmD BACKGROUND The authors of this presentation have the following disclosures concerning possible financial or personal relationships with commercial entities: Brittany Reynolds, Pharm D Candidate: No disclosures. Trista Pfeiffenberger, PharmD: No disclosures. Monique Alford, PharmD: No disclosures Pharmacists have an opportunity at the time of discharge to monitor for medication discrepancies and prevent adverse drug events. The Transitional Care program aims to prevent adverse drug events and improve continuity of care for patients after hospital discharge. Community Care of North Carolina (CCNC) is a group of nurse case managers and pharmacists who work with primary care providers (PCPs) as part of patient centered medical homes. AccessCare is a network of CCNC which covers 24 of North Carolina’s 100 counties. One component of AccessCare’s Transitional Care program involves a pharmacist conducting reconciliation and clinical review of medications on eligible hospitalized patients both during the hospital stay and at the time of discharge. OBJECTIVES RISK FACTORS FOR READMISSION REFEFENCES DATA COLLECTION FORM Inclusion: Medicaid or dually eligible Medicare/Medicaid patients who received inpatient and discharge reconciliation services by an AccessCare pharmacist on or after July 1, Exclusion: Patients who are discharged to a facility in which medications are managed and administered by staff (sub-acute or long term care). The study population will include 50 patients with a first admission to the hospital and 50 patients with a readmission to the hospital, both within the most recent 6 month period. Design: Retrospective, observational study Methods: Data will be collected from the following sources NC Medicaid claims information CCNC case management information system CCNC medication reconciliation documentation form Documentation of communication between AccessCare pharmacist and hospitalist or PCP. Analysis: Descriptive statistics will be used to compare the characteristics of patients with their first admission against patients with a previous admission in a six month period. METHODS PATIENT DEMOGRAPHICS Patient Identifier:Age: Patient’s first admission within last 6 mos?  Yes  NoLength of Stay: _______ days Aged, Blind, Disabled status?  Yes  NoDual eligible?  Yes  No Case Management Status:  Medium  Heavy  Deferred  Pending Primary Discharge Diagnosis From Current Admission: _________________________ Co-morbid Conditions:  ADHD/ADD  Anxiety  Asthma  Bipolar  Blood/Blood forming organs  Cancer  Cerebrovascular/CVA  CHF  Chronic Pain  CKD  COPD  CVD  Depression  Diabetes  Endocrine/Metabolic  Genital/Urinary  GI  HTN/CVD  ID/Parasitic Dx  Liver  Muscular/Skeletal  Nervous System  Psychosis  PTSD  Respiratory  Schizophrenia  Skin Diseases Previous admissions in last 6 months: Date:__________________ Primary Discharge Diagnosis:____________________________ Total Number of Medications: ________________________ MEDICATION DISCREPANCIES Discrepant Drug Name High Risk Medication? Discrepancy Type (#) UrgencyTiming  Yes  No  Urgent  Non-urgent  Pre-hospital  During/Post-hospital  Unknown  Yes  No  Urgent  Non-urgent  Pre-hospital  During/Post-hospital  Unknown  Yes  No  Urgent  Non-urgent  Pre-hospital  During/Post-hospital  Unknown PROVIDER RECOMMENDATIONS AND FOLLOW UP Recommendation(s) sent to:  Hospitalist  PCP Follow-up from PCP:  Received; accepted ____/_____ recommendations  No follow-up documented Follow-up from Hospitalist:  Received; accepted ____/_____ recommendations  No follow-up documented DISCREPANCY IDENTIFICATION KEY 1.Discontinued medication per discharge instructions, but still taking 2.Not taking prescribed discharge medications 3.Poor adherence to chronic medication (pre-hospital visit) 4.Medications dose/frequency/duration 5.Potential transcription error, combo drug, misnaming 6. Absolute contraindication (Drug-drug, drug-dz, drug-food) 7. Interaction non-absolute (Drug-drug, drug- dz, drug-food) 8. Adverse event/side effect reported 9. Drug allergy 10. Therapeutic duplication 11. Unconfirmed discontinuation 12. Unreported medications DISCLOSURES 1.Forster AJ, Clark HD, et al. Adverse events among medical patients after discharge from hospital. CMAJ 2004;170(3): Forster AJ, Murff HJ, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003;138(3): Kripalani S, LeFevre F, et al. Deficits in communication and information between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007;297(8): Compare medication discrepancies identified and prescriber follow up received in patients admitted for the first time versus readmitted patients, both of whom receive discharge medication reconciliation services by a hospital based pharmacist. Compare medication discrepancies by high risk status of the drug, discrepancy type, and urgency. Contrast first time admissions against readmissions for discharge diagnosis, total number of medications, comorbid conditions, and other demographic variables. Readmission Early Hospital Discharge 2 Therapeutic Error 1,2 Adverse Drug Effects 1,2 Inadequate Follow Up 3 Disease Progression