Implementation and Assessment of a Pharmacy-Led Inpatient Transitions of Care Program

Objective: To evaluate pharmacist involvement in the inpatient transition of care (TOC) process for patients hospitalized with type 1 diabetes mellitus, type 2 diabetes mellitus, or chronic obstructive pulmonary disease. Methods: A pharmacist screened patients admitted with one or more of the qualifying conditions within 48 hours of admission to perform medication reconciliation. During medication reconciliation, the pharmacist removed any duplicate or nonindicated medications and added any omitted medications. The pharmacist also reviewed the discharge summary to ensure medication optimization upon discharge. Results: Pharmacist involvement in the admission and discharge reconciliation processes of the 50 identified patients was 100% and 44%, respectively. A medication-related problem was identified in 96% (n = 48) of patients, representing 338 pharmacist-mediated interventions with an average of 6.8 +/- 4.0 (range 0-16) interventions per patient. Of those 338 interventions, 298 drug discrepancies were identified and corrected, with an average of 6.0 +/- 3.7 (range 0-15) discrepancies per patient. Average time spent was 66 +/- 22 (range 30-130) minutes with each patient. Of the 50 patients enrolled, 12 were readmitted within 30 days. Conclusions: This pilot study demonstrated an improved medication reconciliation process with pharmacist involvement, expanding the body of evidence that pharmacists can enhance TOC management in an inpatient setting. These results highlight the utility of a pharmacist in the implementation and refinement of TOC services and provides impetus for a team-based approach when patients experience a TOC.