Pharmacists’ Involvement in Medication Management Along the Continuum of Care: Challenges, Lessons Learned, and Implications for Health Systems

• Background: Medication management is becoming more complex, with new medications entering the market, drug prices increasing, and patients transferring into and out of the hospital. Transitions of care services are being implemented to prevent readmissions and increase patient satisfaction. Pharmacists play a key role by expanding clinical services provided to patients around medication management. • Objective: To describe a pharmacy transitions of care model at a large academic teaching hospital and lessons learned during implementation. • Methods: A pharmacy bundle of services was initially developed in a medical patient population and included medication reconciliation, patient education targeting high-risk medications, post-discharge follow-up phone calls, and bedside discharge prescription delivery. This bundle was expanded to other patient populations through the use of residency-trained pharmacists, pharmacy residents, pharmacy students, and certified pharmacy technicians. • Results: Challenges were faced when implementing our transitions of care services, including expanding care coordination team coverage with existing resources, training pharmacy staff in new roles, determining the needs of patients cared for by teams we had not previously been integrated into, and creating our discharge prescription delivery program. During this process, we learned to rethink the role of pharmacists on our team, value the support within our institution to create change in order to improve patient care, and continuously evaluate this process. • Conclusion: We are at an opportune time to expand the scope of the inpatient pharmacist to provide advanced medication-related services to patients. Residency training is creating individuals who will thrive in these new models. Medication management around the acute care inpatient stay is a challenging but crucial task to ensure patient safety and desired clinical outcomes. The first step in successful medication management is to understand the patient’s medication regimen in the home environment. Patients may take medications differently than prescribed; skip medication doses intentionally to make a supply last longer; use over-the-counter medications, herbal supplements, or someone else’s medication based on the recommendation of family or friends; or discontinue medications based on side effects or media influence. Over the course of the inpatient stay, medication management involves adjusting doses based on changes in organ function, detecting side effects and potential drug interactions, and monitoring clinical outcomes to ensure appropriate drug therapy is being prescribed. As the patient approaches discharge, ensuring the patient understands the indications for his/her medications, has self-monitoring techniques to Pharmacists’ Involvement in Medication Management Along the Continuum of Care: Challenges, Lessons Learned, and Implications for Health Systems Vi Gilmore, PharmD, BCPS, Meghan Swarthout, PharmD, MBA, BCPS, Todd Nesbit, PharmD, MBA, Virna Almuete, PharmD, Jennifer Gillespie, PharmD, MBA, Denise Fu, PharmD, BCACP, and Leigh Efird, PharmD, MPH, BCPS From The Johns Hopkins Hospital, Baltimore, MD. The project described was supported by grant # 1C1CMS331053-01-00 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented was conducted by the awardee. Findings may or may not be consistent with or confirmed by the findings of the independent evaluation contractor.