ASHP Best Practices Award Mortar and Pestle

Award Information

Advancing Pharmacy Practice in Transitions of Care: Post-Hospitalization Ambulatory Medication Reconciliation at a Patient Centered Medical Home

Candice Garwood, Pharm.D., FCCP, BCPS, Victoria Liu, Pharm.D, Ann Balarezo, GNP-BC, Bibban Deol, M.D., Marybeth Lepczyk, ACNS-BC, Annie Allen, LMSW, Melissa Lipari, Pharm.D., BCACP, David Trupiano, Pharm.D., Lavoisier Cardozo, M.D., Joel Steinberg, M.D., Belenda House, Joanne MacDonald, Pharm.D., David Bach Pharm.D., M.P.H., Kim Tsilimingras, B.S. Pharm., Greg Polk, B.S. Pharm, M.B.A.


Detroit Medical Center, Detroit, Michigan

Inadequate medication reconciliation at transitions of care is believed to account for 46% of medication errors, with 20% of those resulting in harm.1 To address this concern, a multidisciplinary transition of care program was developed in our medical home clinic. The purpose of the program was to make post-hospital discharge phone calls to reconcile patients' medication use with the electronic medical record (EMR) and resolve identified medication related problems (MRPs). Ultimately, our goal was to prevent adverse drug events and facilitate a seamless transition of care from the hospital to home to the primary care clinic.

Pharmacy students, residents, and a clinical pharmacy specialist call patients upon discharge. Working under a collaborative drug therapy management agreement, pharmacists identify and resolve MRPs by optimizing treatment, assisting in obtaining medication supply, providing patient education, and ensuring accurate medication documentation.

The program was implemented March 2012. From March to October 2012, there were 527 eligible index discharges with medication reconciliation completed for 93. Our program demonstrated non-significant reductions in acute healthcare utilization for those receiving medication reconciliation calls compared with those not receiving calls; 30-day readmission (20.00% vs. 21.16%, OR 1.074; 95% CI 0.437-2.638); 30-day acute healthcare utilization rates (27.27% vs. 35.24%, OR 1.45; 95% CI 0.837-2.514). Patients receiving medication reconciliation calls showed trends towards increased length between hospital encounters (52 days vs. 38 days, p=0.0691). A majority of the phone calls (81.7%) had at least one MRP, with an average of 32 MRPs per call. Many MRPs required patient education (37.1%) and several required immediate medication change to ensure safety (6.3%). Our program created infrastructure change and improvements in information sharing through technology, i.e., new documentation systems and a new pharmacist profile in the EMR. Components of our clinic’s post-discharge phone call model and documentation process were utilized to develop a new integrated inpatient pharmacy practice model for transitions of care. Pharmacist services were expanded, targeting medication reconciliation and counseling across inpatient care areas. Furthermore, the number of students and residents precepted in our clinic doubled and a new inpatient advance practice rotation was created emphasizing medication reconciliation.

Our clinic’s transitions of care process is an innovative program incorporating multidisciplinary teamwork and expansion of the pharmacist role. The program has improved patient care through identification and resolution of MRPs and continues to influence our pharmacy practice model. Finally, pharmacy trainees experience patient centered continuous care through vulnerable care transitions.

1. Barnsteiner JH. Medication reconciliation: transfer of medication information across settings-keeping it free from error. Am J Nurs. 2005; 105(3 Suppl):31-6.

View a pdf of the poster from the Midyear Meeting (259 KB)