Medication Management Challenges and Opportunities during Care Transitions
Background: Medication management has been reported as the most challenging aspect of transitional care and medication-related problems are the most prevalent adverse event following hospital discharge. Research findings from our team revealed that patients with multiple chronic conditions have an average of 4-7 medication discrepancies following hospital discharge and that identifying and resolving medication discrepancies significantly reduces acute care utilization and costs.
Methods: Studies conducted by our team include: (1) a non-randomized cohort study involving 201 patients ≥ 50 years of age admitted to a home health care agency to test the impact of a pharmacist home visit in identifying and resolving medication discrepancies;1 (2) a randomized clinical trial of patients transitioning from acute care to home health care (n=232) to test the effect of nurse interventionists who were trained to identify and resolve medication discrepancies;2 (3) a secondary analysis of medication regimen complexity of hospital discharge medication lists versus the regimen complexity of medications participants actually reported taking once home (n=213);3 (4) a qualitative study involving focus groups (n=10) of stakeholders (n=69) that included physicians, nurses, pharmacists, social workers, health plan administrators, and health care lawyers to identify strategies for reducing transitional care medication discrepancies and improving patient safety;3 and (5) a randomized clinical trial (n=140) that tested a pharmacist-led medication information transfer intervention in patients with CKD recently discharged from the hospital to home.4
Results: In each of the prospective studies, medication discrepancies were common and pervasive among hospitalized adult patients transitioning to home. Stakeholders were uniformly aware of the limitations and ineffectiveness of medication reconciliation during hospitalization and the limitations of hospital discharge teaching for home medication management following discharge. Medication regimens patients reported taking in the home were less complex than those listed on hospital discharge medication lists, and patients with less complex regimens were at lower risk for adverse drug events. Home visits following hospital discharge by pharmacists or nurses nearly always led to additional interventions to improve safe medication management, even among patients who believed they were managing their medications well.
Lessons Learned: Current transitional care interventions often use telephone follow-up, yet our findings suggest home visits are essential to identifying and resolving discrepancies and other medication management problems. Other finding suggest transitional care interventions that can be done to improve safety include simplifying medication regimens to the extent possible, using teach back, and having the patient/family demonstrate medication administration. Health system solutions to improve medication information transfer between providers, patients, and families are also critical.