1. 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
Add map, add med rec pic, flow diagram of med rec, little copy of the poster
Move risk factors into background section below)
Move objective and patients to middle colume. Combine patient population and methods
Number and add references to picture
Delete hospital patient records
BACKGROUND
OBJECTIVES
DATA COLLECTION FORM
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. 
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. 
PATIENT DEMOGRAPHICS
Patient Identifier:
Age:
Patient’s first admission within last 6 mos? Yes No
Length of Stay: _______ days
Aged, Blind, Disabled status? Yes No
Dual 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 (#)
Urgency
Timing
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
DISCREPANCY IDENTIFICATION KEY
Discontinued medication per discharge instructions, but still taking
Not taking prescribed discharge medications
Poor adherence to chronic medication (pre-hospital visit)
Medications dose/frequency/duration
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
METHODS
RISK FACTORS FOR READMISSION
Inclusion: Medicaid or dually eligible Medicare/Medicaid patients who received inpatient and discharge reconciliation services by an AccessCare pharmacist on or after July 1, 2010.
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.
Readmission
Early Hospital Discharge2
Therapeutic Error1,2
Adverse Drug Effects1,2
Inadequate Follow Up3
Disease Progression