title: Impact of a transition-of-care pharmacist during hospital discharge.
abstract: OBJECTIVE
  To assess the impact of a transition-of-care pharmacist during hospital discharge.
  
  
  METHODS
  An academic medical center in southern Arizona.
  
  
  METHODS
  One pharmacist coordinated patient discharges in two inpatient units from August 2012 through July 2013. The pharmacist attended interdisciplinary discharge coordination meetings, ensured appropriate discharge orders, facilitated the filling of medications, and educated patients on discharge medications.
  
  
  METHODS
  The implementation of a transition-of-care pharmacist to provide discharge medication reconciliation and education.
  
  
  METHODS
  Readmission rates and medication interventions made by the pharmacist at discharge.
  
  
  RESULTS
  The pharmacist was involved in the education of 1,011 patients and performed 452 interventions. There were more readmissions per month in the control year versus the year of pharmacist involvement (median 27.5 vs. 25, P = 0.0369). Interventions made by the pharmacist to improve discharge management included starting an omitted medication (23.5%), preventing multiple discharge problems (16.4%), avoiding duplication of therapy (15.7%), correcting insurance issues related to medication coverage (12.2%), changing an improper medication dose or quantity (11.3%), changing an inappropriate prescription for a medication (5.1%), preventing a drug interaction (3.3%), and resolving other problems (12.6%). The most common medication classes involved were antimicrobial agents (9.1%), anticoagulants (8%), antihyperglycemic agents (3.8%), other drug classes (24%), and multiple drug classes (35%).
  
  
  CONCLUSIONS
  A transition-of-care pharmacist is in a unique position to educate patients on hospital discharge, to intercept a substantial number of medication errors, and to resolve insurance issues that may lead to adherence problems. These improvements in care may result in reduced hospital readmission rates.
authors.forename: Lauren
authors.initials: L
authors.lastname: Balling
authors.forename: Brian L
authors.initials: BL
authors.lastname: Erstad
authors.forename: Kurt
authors.initials: K
authors.lastname: Weibel
mesh_terms: D000046:Academic Medical Centers; D001130:Arizona; D004347:Drug Interactions; D064420:Drug-Related Side Effects and Adverse Reactions / Q000517:prevention & control; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D057970:Inappropriate Prescribing / Q000517:prevention & control; D007356:Insurance, Pharmaceutical Services; D055118:Medication Adherence; D059065:Medication Reconciliation / Q000592:standards; D010351:Patient Discharge / Q000592:standards; D010353:Patient Education as Topic; D010359:Patient Readmission; D010360:Patient Transfer / Q000592:standards; D010595:Pharmacists / Q000592:standards; D024382:Professional Role; D015397:Program Evaluation; D058996:Quality Improvement; D000078329:Workforce