Medication Reconciliation at Transition of Care in a Geriatric Primary Care Setting: A Pilot Program

Background: The transition from hospital to home for older individuals can be complicated, as they are more likely to have complex health and/or social care needs. Several published studies have outlined positive outcomes from pharmacist-driven transition of care programs. At our four geriatric primary care clinics affiliated with a large academic medical center, there is no medication reconciliation process to evaluate a patient's medications after being discharged from the hospital to home. Objective: The objective of this pilot program was to demonstrate the need for a pharmacist-led transition of care medication reconciliation program within a geriatric primary care setting. Design: This is a retrospective evaluation of a pilot program that took place from July 1, 2022, to June 30, 2023, within 4 geriatric primary care clinics affiliated with a 523-bed, full-service medical and surgical acute care hospital. Electronic medical records (EMR) were utilized to identify patients who were discharged from the hospital within 24 to 72 hours to their homes. Documentation in the patient's EMR by the primary care clinic's clinical pharmacist contained confirmation of a hospital follow-up appointment, completion of medication reconciliation, notification to the provider for pharmacotherapy concerns, and patient counseling on medication changes. Information on number of patients requiring clinical pharmacist intervention prior to hospital follow-up appointment, intervention type, average number of medication discrepancies per patient, and percentage of hospital follow-up appointments with a medication reconciliation completed prior to visit were also documented. Setting: Four geriatric primary care clinics affiliated with a 523-bed, full-service medical and surgical acute care hospital in Gainesville, Florida. Patients, Participants: A total of 881 unique medication reconciliations were completed for this retrospective pilot program study. Patients were included if they were discharged from the hospital to home during that time period and were active patients of a provider at the primary care clinic. Patients were excluded if they were discharged from the hospital to another acute care facility (such as a skilled nursing facility, rehabilitation facility, or hospice), if the patient expired during their hospitalization, or if they were not an active patient of a provider at the primary care clinic. Intervention: A primary care clinical pharmacist reviewed each discharged patient's EMR from the hospital to reconcile their medications with the medication list within the patient's primary care EMR. A transitions of care medication reconciliation evaluation progress note was created for each patient discharged home for documentation. Within this note, the pharmacist documented the number of medication discrepancies, medications added, medications discontinued, and medications with dosage adjustments. The pharmacist would contact the patient to clarify any urgent medication concerns and confirm that they made the appropriate medication adjustments as instructed at discharge from the hospital. If the clinical pharmacist had additional pharmacotherapy concerns, they would contact the provider prior to the hospital follow-up appointment. This was counted as an intervention. The intervention type was classified into categories based on the issue as determined by the clinical pharmacist: new medication, medication omission, high-risk medication, clarify administration frequency, clarify dose, and other reasons. Methods: Data from EMRs identified patients discharged home from the hospital within the last 24-72 hours between July 1, 2022, and June 30, 2023. Medication reconciliation was documented in the patient's EMR. The following elements were included: confirmation of a hospital follow-up appointment, notification to the provider for pharmacotherapy concerns, and patient counseling on medication changes. Results: A total of 881 patient evaluations were included in this study; and these evaluations identified 4,895 medication discrepancies with an average of 5.5 discrepancies per patient. Prior to the hospital follow-up appointment, 267 patients (30.3%) required clinical pharmacist intervention. By the end of the study period, 96.3% of hospital follow-up appointments had a medication reconciliation completed by a clinical pharmacist prior to the visit. Conclusion: This pharmacist-led medication reconciliation program within a geriatric primary care setting confirms a gap in care during transition from hospital to home. It was able to identify medication discrepancies and educate patients about medication changes.