1. UAMC – Discharge Medication Optimization Lauren Miller, PharmD. Instructor University of Arizona College of Pharmacy Clinical Staff Pharmacist Ambulatory Services, UAMC Hospital

2. Pharmacist Pilot Program: From Discharge to the First Refill One full time pharmacist One full time pharmacist 2 inpatient units 2 inpatient units focused on discharges only focused on discharges only Attend daily care coordination meetings on each floor with nurses, case managers, and social workers to identify high risk patients and plan safe discharges from admission Attend daily care coordination meetings on each floor with nurses, case managers, and social workers to identify high risk patients and plan safe discharges from admission

3. Responsibilities Review discharge medication orders Review discharge medication orders Duplicates Duplicates DDI DDI Missing medications or prescriptions Missing medications or prescriptions Remove unnecessary meds Remove unnecessary meds Coordinate prior authorizations ahead of time and assist patients unable to afford meds Coordinate prior authorizations ahead of time and assist patients unable to afford meds Assist patients to fill at hospital pharmacy so they can leave with all new medications Assist patients to fill at hospital pharmacy so they can leave with all new medications Counsel on medications and education on disease states at bedside Counsel on medications and education on disease states at bedside

4. What has worked…. Team based transitions of care with nurses, case managers, social workers, and MD all involved Team based transitions of care with nurses, case managers, social workers, and MD all involved All members of the above team now rely on me to assist more difficult discharges and alert me to patients who need my assistance All members of the above team now rely on me to assist more difficult discharges and alert me to patients who need my assistance Good response from patients who like getting their medication problems resolved prior to discharge Good response from patients who like getting their medication problems resolved prior to discharge

5. Challenges How to determine when discharge order is in How to determine when discharge order is in Subscribe to discharge pager for both units Subscribe to discharge pager for both units Have nurses contact me Have nurses contact me Have to wait until discharge is finalized to review meds for accuracy Have to wait until discharge is finalized to review meds for accuracy Multiple patients can be discharged at the same time how to see all of them Multiple patients can be discharged at the same time how to see all of them Getting MDs on board with new program Getting MDs on board with new program

6. Examples of Errors Caught Numerous DDI when home meds restarted Numerous DDI when home meds restarted Discharges with duplicate meds Discharges with duplicate meds Patients discharged without scripts for new meds Patients discharged without scripts for new meds New diabetics leaving without Rx for meters or syringes New diabetics leaving without Rx for meters or syringes Patients leaving without INR follow-up for new start coumadin Patients leaving without INR follow-up for new start coumadin Provide assistance to patients unable to afford or changing to meds patients can afford Provide assistance to patients unable to afford or changing to meds patients can afford Incorrect dosing on discharge meds Incorrect dosing on discharge meds

7. Data Being Collected Number of patients interacting with discharge pharmacist including: Number of patients interacting with discharge pharmacist including: Number of meds counseled on Number of meds counseled on Type of error that was caught and class of medication Type of error that was caught and class of medication If insurance authorization was needed If insurance authorization was needed Amount of time spent on each discharge Amount of time spent on each discharge Readmission rates before and after Readmission rates before and after HCAHPS scores HCAHPS scores Patients ranking of communication about medications (from hospital survey after discharge) Patients ranking of communication about medications (from hospital survey after discharge)