title: Development and implementation of a postdischarge home-based medication management service.
abstract: OBJECTIVE
  The development and implementation of a postdischarge home-based, pharmacist-provided medication management service are described.
  
  
  CONCLUSIONS
  A work group composed of pharmacy administrators, clinical specialists, physicians, and nursing leadership developed the structure and training requirements to implement the service. Eligible patients were identified during their hospital admission by acute care pharmacists and consented for study participation. Pharmacists and pharmacy residents visited the patient at home after discharge and conducted medication reconciliation, provided patient education, and completed a comprehensive medication review. Recommendations for medication optimization were communicated to the patient's primary care provider, and a reconciled medication list was faxed to the patient's community pharmacy. Demographic and medication-related data were collected to characterize patients receiving the home-based service. A total of 50 patients were seen by pharmacists in the home. Patient education provided by the home-based pharmacists included monitoring instructions, adherence reinforcement, therapeutic lifestyle changes, administration instructions, and medication disposal instructions. Pharmacists provided the following recommendations to providers to optimize medication regimens: adjust dosage, suggest laboratory tests, add medication, discontinue medication, need prescription for refills, and change product formulation. Pharmacists identified a median of two medication discrepancies per patient and made a median of two recommendations for medication optimization to patients' primary care providers.
  
  
  CONCLUSIONS
  The implementation of a post-discharge, pharmacist-provided home-based medication management service enhanced the continuity of patient care during the transition from hospital to home. Pharmacists identified and resolved medication discrepancies, educated patients about their medications, and provided primary care providers and community pharmacies with a complete and reconciled medication list.
authors.affiliation: Emily C. Pherson, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine, Johns Hopkins Hospital, Baltimore, MD. Kenneth M. Shermock, Pharm.D., Ph.D., is Director, Center for Medication Quality and Outcomes, Johns Hopkins Hospital, and Assistant Professor, General Internal Medicine, Johns Hopkins School of Medicine, Baltimore. Leigh E. Efird, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; Vi T. Gilmore, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Todd Nesbit, Pharm.D., M.B.A., is Associate Director, Decentralized and Clinical Services, Department of Pharmacy, Johns Hopkins Hospital. Yvonne LeBlanc, Pharm.D., M.B.A., CGP, is Associate Clinical Editor, Natural Standard Research Collaboration, Somerville, MA. Daniel J. Brotman, M.D., SFHM, FACP, is Director, Hospitalist Program, and Associate Professor of Medicine; Amy Deutschendorf, B.S.N., M.S.N., RN, ACNS-BC, is Senior Director, Utilization/Clinical Resource Management; and Meghan Davlin Swarthout, Pharm.D., M.B.A., BCPS, is Division Director, Ambulatory and Care Transitions, Department of Pharmacy, Johns Hopkins Hospital. ecpherson@jhmi.edu.
authors.forename: Emily C
authors.initials: EC
authors.lastname: Pherson
authors.affiliation: Emily C. Pherson, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine, Johns Hopkins Hospital, Baltimore, MD. Kenneth M. Shermock, Pharm.D., Ph.D., is Director, Center for Medication Quality and Outcomes, Johns Hopkins Hospital, and Assistant Professor, General Internal Medicine, Johns Hopkins School of Medicine, Baltimore. Leigh E. Efird, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; Vi T. Gilmore, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Todd Nesbit, Pharm.D., M.B.A., is Associate Director, Decentralized and Clinical Services, Department of Pharmacy, Johns Hopkins Hospital. Yvonne LeBlanc, Pharm.D., M.B.A., CGP, is Associate Clinical Editor, Natural Standard Research Collaboration, Somerville, MA. Daniel J. Brotman, M.D., SFHM, FACP, is Director, Hospitalist Program, and Associate Professor of Medicine; Amy Deutschendorf, B.S.N., M.S.N., RN, ACNS-BC, is Senior Director, Utilization/Clinical Resource Management; and Meghan Davlin Swarthout, Pharm.D., M.B.A., BCPS, is Division Director, Ambulatory and Care Transitions, Department of Pharmacy, Johns Hopkins Hospital.
authors.forename: Kenneth M
authors.initials: KM
authors.lastname: Shermock
authors.affiliation: Emily C. Pherson, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine, Johns Hopkins Hospital, Baltimore, MD. Kenneth M. Shermock, Pharm.D., Ph.D., is Director, Center for Medication Quality and Outcomes, Johns Hopkins Hospital, and Assistant Professor, General Internal Medicine, Johns Hopkins School of Medicine, Baltimore. Leigh E. Efird, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; Vi T. Gilmore, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Todd Nesbit, Pharm.D., M.B.A., is Associate Director, Decentralized and Clinical Services, Department of Pharmacy, Johns Hopkins Hospital. Yvonne LeBlanc, Pharm.D., M.B.A., CGP, is Associate Clinical Editor, Natural Standard Research Collaboration, Somerville, MA. Daniel J. Brotman, M.D., SFHM, FACP, is Director, Hospitalist Program, and Associate Professor of Medicine; Amy Deutschendorf, B.S.N., M.S.N., RN, ACNS-BC, is Senior Director, Utilization/Clinical Resource Management; and Meghan Davlin Swarthout, Pharm.D., M.B.A., BCPS, is Division Director, Ambulatory and Care Transitions, Department of Pharmacy, Johns Hopkins Hospital.
authors.forename: Leigh E
authors.initials: LE
authors.lastname: Efird
authors.affiliation: Emily C. Pherson, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine, Johns Hopkins Hospital, Baltimore, MD. Kenneth M. Shermock, Pharm.D., Ph.D., is Director, Center for Medication Quality and Outcomes, Johns Hopkins Hospital, and Assistant Professor, General Internal Medicine, Johns Hopkins School of Medicine, Baltimore. Leigh E. Efird, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; Vi T. Gilmore, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Todd Nesbit, Pharm.D., M.B.A., is Associate Director, Decentralized and Clinical Services, Department of Pharmacy, Johns Hopkins Hospital. Yvonne LeBlanc, Pharm.D., M.B.A., CGP, is Associate Clinical Editor, Natural Standard Research Collaboration, Somerville, MA. Daniel J. Brotman, M.D., SFHM, FACP, is Director, Hospitalist Program, and Associate Professor of Medicine; Amy Deutschendorf, B.S.N., M.S.N., RN, ACNS-BC, is Senior Director, Utilization/Clinical Resource Management; and Meghan Davlin Swarthout, Pharm.D., M.B.A., BCPS, is Division Director, Ambulatory and Care Transitions, Department of Pharmacy, Johns Hopkins Hospital.
authors.forename: Vi T
authors.initials: VT
authors.lastname: Gilmore
authors.affiliation: Emily C. Pherson, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine, Johns Hopkins Hospital, Baltimore, MD. Kenneth M. Shermock, Pharm.D., Ph.D., is Director, Center for Medication Quality and Outcomes, Johns Hopkins Hospital, and Assistant Professor, General Internal Medicine, Johns Hopkins School of Medicine, Baltimore. Leigh E. Efird, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; Vi T. Gilmore, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Todd Nesbit, Pharm.D., M.B.A., is Associate Director, Decentralized and Clinical Services, Department of Pharmacy, Johns Hopkins Hospital. Yvonne LeBlanc, Pharm.D., M.B.A., CGP, is Associate Clinical Editor, Natural Standard Research Collaboration, Somerville, MA. Daniel J. Brotman, M.D., SFHM, FACP, is Director, Hospitalist Program, and Associate Professor of Medicine; Amy Deutschendorf, B.S.N., M.S.N., RN, ACNS-BC, is Senior Director, Utilization/Clinical Resource Management; and Meghan Davlin Swarthout, Pharm.D., M.B.A., BCPS, is Division Director, Ambulatory and Care Transitions, Department of Pharmacy, Johns Hopkins Hospital.
authors.forename: Todd
authors.initials: T
authors.lastname: Nesbit
authors.affiliation: Emily C. Pherson, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine, Johns Hopkins Hospital, Baltimore, MD. Kenneth M. Shermock, Pharm.D., Ph.D., is Director, Center for Medication Quality and Outcomes, Johns Hopkins Hospital, and Assistant Professor, General Internal Medicine, Johns Hopkins School of Medicine, Baltimore. Leigh E. Efird, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; Vi T. Gilmore, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Todd Nesbit, Pharm.D., M.B.A., is Associate Director, Decentralized and Clinical Services, Department of Pharmacy, Johns Hopkins Hospital. Yvonne LeBlanc, Pharm.D., M.B.A., CGP, is Associate Clinical Editor, Natural Standard Research Collaboration, Somerville, MA. Daniel J. Brotman, M.D., SFHM, FACP, is Director, Hospitalist Program, and Associate Professor of Medicine; Amy Deutschendorf, B.S.N., M.S.N., RN, ACNS-BC, is Senior Director, Utilization/Clinical Resource Management; and Meghan Davlin Swarthout, Pharm.D., M.B.A., BCPS, is Division Director, Ambulatory and Care Transitions, Department of Pharmacy, Johns Hopkins Hospital.
authors.forename: Yvonne
authors.initials: Y
authors.lastname: LeBlanc
authors.affiliation: Emily C. Pherson, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine, Johns Hopkins Hospital, Baltimore, MD. Kenneth M. Shermock, Pharm.D., Ph.D., is Director, Center for Medication Quality and Outcomes, Johns Hopkins Hospital, and Assistant Professor, General Internal Medicine, Johns Hopkins School of Medicine, Baltimore. Leigh E. Efird, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; Vi T. Gilmore, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Todd Nesbit, Pharm.D., M.B.A., is Associate Director, Decentralized and Clinical Services, Department of Pharmacy, Johns Hopkins Hospital. Yvonne LeBlanc, Pharm.D., M.B.A., CGP, is Associate Clinical Editor, Natural Standard Research Collaboration, Somerville, MA. Daniel J. Brotman, M.D., SFHM, FACP, is Director, Hospitalist Program, and Associate Professor of Medicine; Amy Deutschendorf, B.S.N., M.S.N., RN, ACNS-BC, is Senior Director, Utilization/Clinical Resource Management; and Meghan Davlin Swarthout, Pharm.D., M.B.A., BCPS, is Division Director, Ambulatory and Care Transitions, Department of Pharmacy, Johns Hopkins Hospital.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Brotman
authors.affiliation: Emily C. Pherson, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine, Johns Hopkins Hospital, Baltimore, MD. Kenneth M. Shermock, Pharm.D., Ph.D., is Director, Center for Medication Quality and Outcomes, Johns Hopkins Hospital, and Assistant Professor, General Internal Medicine, Johns Hopkins School of Medicine, Baltimore. Leigh E. Efird, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; Vi T. Gilmore, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Todd Nesbit, Pharm.D., M.B.A., is Associate Director, Decentralized and Clinical Services, Department of Pharmacy, Johns Hopkins Hospital. Yvonne LeBlanc, Pharm.D., M.B.A., CGP, is Associate Clinical Editor, Natural Standard Research Collaboration, Somerville, MA. Daniel J. Brotman, M.D., SFHM, FACP, is Director, Hospitalist Program, and Associate Professor of Medicine; Amy Deutschendorf, B.S.N., M.S.N., RN, ACNS-BC, is Senior Director, Utilization/Clinical Resource Management; and Meghan Davlin Swarthout, Pharm.D., M.B.A., BCPS, is Division Director, Ambulatory and Care Transitions, Department of Pharmacy, Johns Hopkins Hospital.
authors.forename: Amy
authors.initials: A
authors.lastname: Deutschendorf
authors.affiliation: Emily C. Pherson, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine, Johns Hopkins Hospital, Baltimore, MD. Kenneth M. Shermock, Pharm.D., Ph.D., is Director, Center for Medication Quality and Outcomes, Johns Hopkins Hospital, and Assistant Professor, General Internal Medicine, Johns Hopkins School of Medicine, Baltimore. Leigh E. Efird, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; Vi T. Gilmore, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Todd Nesbit, Pharm.D., M.B.A., is Associate Director, Decentralized and Clinical Services, Department of Pharmacy, Johns Hopkins Hospital. Yvonne LeBlanc, Pharm.D., M.B.A., CGP, is Associate Clinical Editor, Natural Standard Research Collaboration, Somerville, MA. Daniel J. Brotman, M.D., SFHM, FACP, is Director, Hospitalist Program, and Associate Professor of Medicine; Amy Deutschendorf, B.S.N., M.S.N., RN, ACNS-BC, is Senior Director, Utilization/Clinical Resource Management; and Meghan Davlin Swarthout, Pharm.D., M.B.A., BCPS, is Division Director, Ambulatory and Care Transitions, Department of Pharmacy, Johns Hopkins Hospital.
authors.forename: Meghan Davlin
authors.initials: MD
authors.lastname: Swarthout
mesh_terms: D003266:Continuity of Patient Care / Q000458:organization & administration*; D005260:Female; D018575:Home Care Services, Hospital-Based / Q000458:organization & administration*; D006801:Humans; D008297:Male; D059065:Medication Reconciliation / Q000458:organization & administration*; D008875:Middle Aged; D010348:Patient Care Team / Q000458:organization & administration*; D010353:Patient Education as Topic / Q000379:methods; D010593:Pharmaceutical Services / Q000458:organization & administration*; D016730:Program Development