title: Design and implementation of a targeted approach for pharmacist-mediated medication management at care transitions.
abstract: To improve patient care through the development of a clinical risk stratification tool to identify high-risk patients and implementation of pharmacist-mediated medication management after patient care transitions.
  
  
  
  Minneapolis Veterans Affairs (VA) Health Care System from December 1, 2014, to April 1, 2015.
  
  
  
  A composite care transition score was developed based on risk factors obtained from a literature review and combined with a national stratification tool unique to the Veterans Health Administration (VHA) primary care population, the Care Assessment Need (CAN) score. High-risk individuals were identified to receive a comprehensive medication therapy management (MTM) encounter within 7 days of a recent transition of care. Pharmacists identified and resolved medication-related problems and drug discrepancies using an independent scope of practice.
  
  
  
  Pharmacists with an independent scope of practice, using a novel risk-stratification tool, are able have a positive impact on transitions of care for high-risk patients.
  
  
  
  High-risk patients engaged in comprehensive medication therapy management appointments performed by primary care clinical pharmacists with an independent scope of practice.
  
  
  
  Medication-related problems, drug discrepancies, and pharmacist mediated interventions were analyzed after completion of MTM encounters in 31 high-risk patients. Patient characteristics and time demands per encounter were also assessed.
  
  
  
  A total of 31 patients were seen for MTM encounters. A total of 127 medication-related problems were identified, resulting in an average of 4.1 ± 2.9 (range, 0-14) problems per patient. In addition, 137 drug discrepancies were found during medication reconciliation, with an average of 4.4 ± 2.8 (range, 0-13) discrepancies per patient. Pharmacist-mediated interventions were performed in 84% (n = 26) of patients, totaling 121 interventions with an average of 3.9 ±3.8 (range, 0-13) interventions per patient.
  
  
  
  Stratification of patients and pharmacist-mediated MTM appointments resulted in the identification and resolution of medication-related problems and drug discrepancies at care transitions.
authors.forename: Chris
authors.initials: C
authors.lastname: Ploenzke
authors.forename: Tessa
authors.initials: T
authors.lastname: Kemp
authors.forename: Todd
authors.initials: T
authors.lastname: Naidl
authors.forename: Rebecca
authors.initials: R
authors.lastname: Marraffa
authors.forename: Jennifer
authors.initials: J
authors.lastname: Bolduc
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003266:Continuity of Patient Care / Q000458:organization & administration*; D004282:Documentation; D005260:Female; D006801:Humans; D008297:Male; D054539:Medication Therapy Management / Q000458:organization & administration*; D008875:Middle Aged; D010595:Pharmacists / Q000458:organization & administration*; D010865:Pilot Projects; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors