Post-discharge Medication Reconciliation: Reduction in Readmissions in a Geriatric Primary Care Clinic

Abstract

Objectives: This study aimed to evaluate hospital utilization and characterize interventions of pharmacist-led telephonic post-discharge medication reconciliation. Method: A retrospective analysis was conducted, including 833 index events in 586 geriatric patients receiving the intervention. Medicare claims were used to capture 30-day hospital utilization (admission to the emergency department, observation unit, or inpatient hospitalization) following discharge from any of these locations. Medication-related interventions were described. Results: Hospital utilization within 30 days after discharge from any location was greater for patients receiving usual care compared with the intervention (32.5% vs. 22.2%; odds ratio [OR] = 1.69, 95% confidence interval [CI] = [1.06, 2.68]). Inpatient admission within 30 days after discharge from any location was greater for those receiving usual care (14.7% vs. 6.4%; OR = 2.54, 95% CI = [1.18, 5.44]). At least one medication-related problem was identified and addressed in 89.8% of patients receiving the intervention. Discussion: A telephonic post-discharge medication reconciliation program can lead to reduction in hospital utilization in a geriatric population.

Keywords

medication reconciliation transition of care pharmacists telephone

Introduction

Elderly patients with complex needs and medication regimens transition across care settings frequently. During care transitions, miscommunication between providers and between care settings is common. As a result of poor “handoffs,” patients may become vulnerable to adverse events and increased need for medical care (Coleman & Boult, 2003). Particularly, lack of communication between providers and inadequate education to patients about their medications may lead to discrepancies and errors, which pose risk to patient safety (The Institute of Medicine, 1999). According to one report examining transitions of care medication–related problems in the elderly, 49.2% of medication discrepancies identified within 72 hr of hospital discharge were a result of inadequate discharge instructions to the patient, whereas 50.8% were a result of intentional or nonintentional patient nonadherence (Coleman, Smith, Raha, & Min, 2005). This highlights the importance of careful medication management during care transitions, especially for elderly patients with complicated medication regimens.

Following the Institute of Medicine Report, Crossing the Quality Chasm: A New Health System for the 21st Century, medication errors have drawn increased national attention (The Institute of Medicine, 1999). Medication reconciliation has been promoted as an important patient safety initiative aimed at reducing medication-related errors (Brega et al., 2015). Inadequate medication reconciliation to identify and resolve medication-related problems (MRPs) is believed to account for 46% of all medication errors, with up to 20% of such errors resulting in harm (Barnsteiner, 2005). Adverse drug events may lead a patient to seek additional medical care in the clinic or emergency department (ED), or may even cause safety issues requiring hospitalization. Furthermore, patients discharged home from an institution with medication discrepancies may have a significantly higher 30-day inpatient readmission rate compared with patients discharged without a discrepancy (Coleman et al., 2005).

Medication management provided by clinical pharmacists has been shown to enhance patient safety and clinical outcomes, with the potential to reduce readmissions and costs (Agency for Healthcare Research and Quality, 2012; Agency for Healthcare Research and Quality, 2013; Nigro et al., 2014). Collaborative drug therapy management is a formal partnership between a pharmacist and physician(s) delegating authority to the pharmacist to manage a patient’s drug therapy, and, thus, to identify and resolve MRPs. Several studies have evaluated the impact of pharmacists providing medication-related transitional care services at the time of hospital discharge (Al-Rashed, Wright, Roebuck, Sunter, & Chrystyn, 2002; Budiman, Snodgrass & Chang, 2016; Crotty, Rowett & Spurling, Giles, & Phillips, 2004; Dudas, Bookwalter, Kerr, & Pantilat, 2001; Lipton & Bird, 1994; Nazareth et al., 2001; Schnipper et al., 2006; Smith et al., 1997; Walker et al., 2009). Some studies have demonstrated that hospital pharmacists reduce adverse drug events post-hospitalization by means of patient education and resolution of missing prescriptions and prescription errors (Al-Rashed et al., 2002; Lipton & Bird, 1994; Smith et al., 1997). Other reports present mixed data on the impact of post-discharge telephone follow-up on health care utilization (Anderson, Marrs, Vande Griend, & Hanratty, 2013; Budiman et al., 2016; Dudas et al., 2001; Lipton & Bird, 1994; Nassaralla, Naessens, Chaudhry, Hansen, & Scheitel, 2007; Nazareth et al., 2001; Stranges et al., 2015; Tang, Fujimoto, & Karliner, 2014). Data on pharmacist-led medication reconciliation from the primary care office once the patient is discharged home have shown benefit (Anderson et al., 2013; Stranges et al., 2015; Tedesco, McConaha, Skomo, & Higginbotham, 2016). However, we are unaware of any transitional care studies that characterize the interventions of pharmacists practicing under a collaborative drug therapy management agreement or that describe health care utilization outcomes related to those efforts.

In our quality improvement initiative, we compared the outcomes of patients who received the intervention of pharmacist-led telephonic post-discharge medication reconciliation with the outcomes of patients who did not receive the intervention. The objectives of our study were (a) to evaluate and compare the impact of the intervention on 30-day health care utilization (measured by ED, observation unit, or inpatient admission rates) following an index discharge from any of these locations and (b) to measure the quantity, type, and quality of pharmacy team interventions occurring during telephonic postdischarge medication reconciliation.

Method

Study Setting

The Detroit Medical Center Rosa Parks Wellness Institute for Senior Health is a single-site, multidisciplinary, hospital-based geriatric clinic designated as a patient-centered medical home located in downtown Detroit. The clinic is staffed by seven geriatricians, three nurses, two nurse practitioners, three to four geriatrics fellows, a social worker, and two pharmacists. Approximately 20% of clinic patients are also attributed to the accountable care organization formed by the Detroit Medical Center in 2012.

Program Description

The clinic’s transitions of care program was developed in March 2012 and continues to be in existence today. The program involves a multidisciplinary care team of inpatient and outpatient nurses, nurse practitioners, pharmacists, primary care physicians, a social worker, and clerical staff. The transitions of care program was designed to improve safe medication use and continuity of care for the patient in the time between hospital discharge and follow-up care with their primary care provider in the clinic. Furthermore, the goal of the program was to address any MRPs in the transition period. The transitions of care process begins when the nurse case manager notifies the care team of a patient discharge to home from the ED, observation unit, or inpatient stay. Following this notification, a member of the pharmacy team, which includes pharmacy students, pharmacy residents, and a clinical pharmacy specialist, conducts a telephonic post-discharge medication reconciliation with the patient. At the time of the phone call, the pharmacy team member also confirms that the patient is scheduled for a post-discharge follow-up appointment with a clinic provider. The pharmacy team aims to call patients within 2 days following discharge, but calls are attempted up to the point of the patient’s post–hospital follow-up visit, which is typically scheduled within 14 days of hospital discharge. Calls are attempted 3 times on sequential days without leaving voice messages. The objectives of the phone calls are to reconcile medication use between the primary care and hospital records to assure the patient has obtained his or her medications, to assess safety of and adherence to the medication regimen, and to identify MRPs. Working under a collaborative drug therapy management agreement and in conjunction with the geriatrician when necessary, a pharmacy team member intervenes by counseling the patient, updating the medication records, providing refills, making therapeutic interchanges, and resolving MRPs as appropriate.

All clinic patients known to be discharged home from the ED, observation unit, or inpatient admission of any hospital or health system are eligible for transitions of care program inclusion, and, thus, a medication reconciliation phone call. Patients are excluded from the program if they are discharged to a facility that manages medications for the patient (e.g., hospice, subacute rehabilitation facility, or skilled nursing facility), or if the patient is no longer receiving care from a clinic provider.

Study Groups

Patients reached by telephone for medication reconciliation were included in the intervention group. Patients for whom calls were not attempted or who did not complete a phone call for any reason, such as having an unavailable phone number, the patient not answering the phone, patient refusal, or having a disconnected phone, were considered part of the usual care group.

Data Collection

Data from the patients’ electronic medical records were retrospectively reviewed and collected, including patient characteristics and index event discharge location. Data collection occurred among three investigators and was adjudicated by two of those investigators. An index event was defined as the discharge from first admission to the ED, observation unit, or to inpatient. Specific data were gathered for each MRP identified and for the related pharmacy intervention, then characterized using an adaptation of the University of Southern California Medication Therapy Intervention and Safety Documentation Program User Manual v 6.0 (Chen, 2011). Data gathered included drug name, drug category, source of medication information, categorization of MRP, and classification and severity rating of any potential adverse drug event associated with an MRP. We also described each intervention, the member of the pharmacy team making the call (pharmacist, pharmacy resident, or pharmacy student under supervision), and the amount of time spent on each call. Furthermore, to better assess barriers to the transitions of care program, we gathered descriptive data related to calls attempted but unable to be completed. The clinic leadership entered into a data use agreement with the federally designated health care Quality Improvement Organization for the state of Michigan, acting as an agent for the Centers for Medicare and Medicaid Services (CMS). Evaluation of each patient’s health care utilization was obtained through CMS patient claims data, allowing capture of hospital utilization outside of our health care system. CMS claims data were only available for Medicare beneficiaries, and, thus, were not obtainable for patients who were not Medicare beneficiaries, or who held commercial insurance or some commercial Medicare plans.

Outcomes Measures

The primary outcome measure was the all-cause hospital utilization rate, defined as any hospital admission to the ED, admission to an observation unit, or inpatient admissions within 30 days of the index event. Secondary outcomes were (a) all-cause 30-day inpatient admissions following an index event from any location, (b) all-cause 30-day inpatient readmission following an inpatient-index event, and (c) time to the next hospital use (ED admission, observation stay, or inpatient admission) following the index event discharge. In addition, we performed descriptive analyses to categorize the MRPs and pharmacy team interventions.

Statistical Methods

Data were analyzed using descriptive statistics for patient characteristics, MRPs, and intervention data. Fisher’s exact tests were conducted to test differences between the case and control groups for those variables. Logistical regression analyses were conducted to test the hypothesized relationships between admission to each type of location (ED, observation unit, or inpatient) within 30 days following an index event from any location. Throughout the analyses, a .05 level on a two-sided design-based test of significance represented the cutoff value for assessing statistical significance. All analyses were conducted with SAS 9.13 (SAS Institute Inc, Cary, NC, USA).

Results

During the time period of April 1, 2012, through March 30, 2013, clinic staff was notified of 1,035 index event discharges (Figure 1). Of these, 833 (80.5%) were eligible for the transitions of care program, including telephonic post-discharge medication reconciliation. The mean patient age for the total eligible cohort was 78 (10) years old and 53 (31%) were age 85 years or older. A majority of the eligible index events (n = 833) included patients who were female (n = 616, 74%) and patients who were African American (n = 683, 82%). Most of the eligible index events were discharges from inpatient hospitalization (n = 478, 57.4%) and the remainder consisted of discharges from the ED (n = 247, 29.7%), observation unit (n = 107, 12.8%), and not specified (n = 1, 0.1%).

Figure 1.

Selection diagram for total index events, which includes emergency department, observation unit, and inpatient discharges.

Medication Reconciliation Intervention Phone Calls

Telephonic post-discharge medication reconciliation was conducted for 275 (33%) eligible index events. No call was attempted for 558 (67%) of eligible index events. A call was completed in 166 (60%) of the call attempts (Figure 1). An additional 109 (40%) of the call attempts could not be completed. A majority of noncompleted calls were due to the patient not being reached (n = 66, 60.6%). Other reasons included patient refusal (n = 21, 19.3%), inaccurate or disconnected phone numbers (n = 20, 18.3%), or other (n = 2, 1.8%).

Hospital Utilization Rates

CMS claims data were used to evaluate primary endpoints. These data were available for 126 index events from the intervention group (76% of completed calls) and 443 index events from the usual care group (67% of the 667 total events in the usual care group). Evaluation of hospital use within 30 days was conducted only for the patients with CMS claims data. Baseline demographics comparing the index events for the intervention and usual care groups are included in Table 1.

Table 1.

Characteristics of Patients Included in Medicare Claims Data Analysis.

	Intervention	Usual care	p
	All patients (n = 112)	All patients (n = 323)
	Patient-index events(n = 126)	Patient-index events(n = 443)
Age
<65 years, n (%)	2 (1.59)	31 (7.00)	.13
65-74 years, n (%)	36 (28.57)	118 (26.64)
75-84 years, n (%)	45 (35.71)	135 (30.47)
85-94 years, n (%)	41 (32.54)	146 (32.96)
⩾95 years, n (%)	2 (1.59)	13 (2.93)
Female gender, n (%)	103 (81.8)	328 (74.0)	.08
African American, n (%)	117 (92.9)	368 (83.1)	.006
Discharge location
Inpatient, n (%)	54 (42.85)	258 (58.24)	.008
Observation unit, n (%)	24 (19.05)	57 (12.87)
Emergency department, n (%)	48 (38.10)	128 (28.89)
Comorbidities
Congestive heart failure, n (%)	6 (4.76)	21 (4.74)	1.00
Myocardial infarction, n (%)	3 (2.38)	12 (2.71)
Chronic obstructive pulmonary disease, n (%)	5 (3.97)	18 (4.06)
Other, n (%)	112 (88.89)	392 (88.49)
Length of admission
<4 days, n (%)	108 (85.71)	343 (77.43)	.12
4-8 days, n (%)	15 (11.90)	78 (17.61)
>8 days, n (%)	3 (2.38)	22 (4.97)

The primary endpoint, total hospital utilization within 30 days after index event discharge from any location, was significantly more likely for patients receiving usual care compared with those receiving the intervention, 32.5% versus 22.2%, odds ratio [OR] = 1.69, 95% confidence interval (CI) = [1.06, 2.68], p = .03 (Table 2). In addition, inpatient admission within 30 days after discharge from any location was more likely for those receiving usual care than for those receiving the intervention (14.7% vs. 6.4%; OR = 2.54, 95% CI = [1.18, 5.44], p = .02). No difference was found in 30-day inpatient readmission rates specifically for those discharged from an inpatient setting (12.7% vs. 17.2%; OR = 1.43, 95% CI = [0.61, 3.35], p = .41). The mean time to next inpatient admission (65.7 days vs. 59.4 days, p = .62) or next event of any hospital utilization (71.3 vs. 60.1, p = .24) was not different between the intervention and usual care groups.

Table 2.

Hospital Utilization Within 30 Days After an Index Discharge.

Discharge from:	Admission to:	Intervention(n = 126)number (%)	Usual care(n = 443)number (%)	Odds ratio (95% CI)	p
Any location	Any location	28 (22.2)	144 (32.5)	1.69 [1.06, 2.68]	.03
Any location	Inpatient unit	8 (6.4)	65 (14.7)	2.54 [1.18, 5.44]	.02
Discharge from:	Admission to:	Intervention(n = 55)number (%)	Usual care(n = 267)number (%)	Odds Ratio (95% CI)	p
Inpatient unit	Inpatient unit	7 (12.7)	46 (17.2)	1.43 [0.61, 3.35]	.41

Note. Hospital utilization = admission to an ED, observation unit, or inpatient unit. Index discharge = discharge from an ED, observation unit, or inpatient unit. ED = emergency department.

MRPs

During 166 calls, a total of 597 MRPs were identified with a mean of 3.6 ± 2.7 MRPs per call. Of the patients who received the intervention, 89.8% were found to have at least one MRP. The most common categories of MRPs were medication documentation discrepancies (62.5%) and patient nonadherence (16.8%). In addition, 4.9% of MRPs identified were related to issues of either appropriateness of drug therapy for the indication or effectiveness of prescribed dose, directions, and monitoring, whereas 3.7% of identified MRPs were safety concerns (Table 3). Two percent of the MRPs included a medication error that reached the patient, meaning the patient was taking the erroneous prescription. Approximately 10% of the MRPs had the potential to require health care intervention or hospitalization, including situations involving high-risk medications such as insulin or antithrombotic agents, contraindications to therapy, or drug interactions.

Table 3.

MRPs and Interventions.

Intervention group
Patients, n	148
Patient-index events, n	166
Discharge location
Inpatient, n (%)	78 (47.0)
Observation unit, n (%)	28 (16.9)
Emergency department, n (%)	60 (36.1)
Inpatient, n (%)	78 (47.0)
Call information
Total calls completed, n	166
Mean time spent per call (min)	32.3
Number of total MRPs identified in all calls, n	597
Mean number of MRPs per call	3.6
Personnel making call (n = 166)
PharmD student under supervision, n (%)	79 (47.4)
PGY2 pharmacy resident, n (%)	47 (28.3)
Pharmacist, n (%)	26 (15.9)
PGY1 pharmacy resident, n (%)	14 (8.4)
Category of MRP (n = 597)^a
Documentation discrepancy, n (%)	373 (62.5)
Patient variable/nonadherence, n (%)	100 (16.8)
Supply/administration issues, n (%)	73 (12.2)
Appropriateness for the indication/effectiveness of prescribed drug, dose, directions, monitoring, n (%)	29 (4.9)
Safety, n (%)	22 (3.7)
Classification of ADE or pADE (n = 597)^a
No medication error, but potential for ADE identified, n (%)	582 (97.5)
Medication error, but did not reach the patient, n (%)	3 (0.5)
Medication error, reached the patient but no harm, n (%)	12 (2.0)
Medication error, reached the patient but monitoring required to confirm no harm, n (%)	0 (0)
Severity rating of pADE (n = 597)
Minimal harm: Would require self-management	536 (89.8)
Moderate harm: Would require health intervention/hospitalization to resolve	61 (10.2)
Severe harm: Permanent disability or death	0 (0)
Pharmacist interventions for MRPs (n = 805)^b
Confirmed safe, updated mediation list, n (%)	362 (45.0)
Educated patient, clarified directions, n (%)	212 (26.3)
PCP notified to reevaluate medication at next appointment, n (%)	128 (15.9)
Assisted in obtaining medication supply, n (%)	48 (6.0)
Changed medication, n (%)	32 (4.0)
Discussed with PCP for immediate intervention, n (%)	18 (2.2)
Other, n (%)	5 (0.6)

Note. MRP = medication reconciliation problem; ADE = adverse drug event; pADE = potential adverse drug event; PCP = primary care provider.

Multiple MRPs and ADE/pADE were found per call.

Multiple interventions were conducted per MRP.

Multiple interventions were related to a single MRP, such that 805 interventions occurred overall. A great proportion of MRPs required patient education (35.5%) and several involved medication changes to ensure safety (5.4%). A few MRPs required discussion with the primary care provider for urgent intervention (3%). The mean time spent per call was 32 (15) min. Almost half of the calls (47.6%) required 15 to 30 min to complete.

Discussion

We found that a transitions of care program, including telephonic medication reconciliation following discharge from the ED, observation unit, or inpatient admission can lead to reduction in hospital utilization, and specifically all-cause inpatient admission, within 30 days in an elderly population. Pharmacists and pharmacy students conducting the calls identified a mean of 3.6 MRPs per call. Approximately 2% of MRPs with the potential to cause an adverse effect reached the patient, meaning the patient took the prescription. Pharmacists working under a collaborative drug therapy management agreement were able to address these problems in a number of ways, including educating patients, updating documentation, assisting with medication access, and interchanging medications.

Our study demonstrates the value of post-discharge follow-up by pharmacists in a medically underserved, minority elderly population of primarily lower socioeconomic status. Our patients are more likely to reside within a federally designated medically underserved area, have higher mortality, and have a greater likelihood of being hospitalized than their counterparts elsewhere in the state of Michigan. Statewide hospitalization rates for individuals aged 75 and older are approximately 4,500 per 10,000 people, and rates for Detroit are 30% higher (Kallenbach & Smitherman, 2018).

Another unique attribute of our study is that we evaluated hospital utilization as an outcome, including use of the ED, observation unit, and inpatient hospitalization. Several studies focus only on inpatient readmission or ED visits as an outcome (Anderson et al., 2013; Stranges et al., 2015). Our study is robust as it provides broader inclusion of real-world health care use. Given that hospital utilization often crosses multiple health systems in a large metropolitan area, our data are particularly relevant as we utilized CMS claims data to capture hospital utilization beyond our own health system. We did, however, experience some limitations in capturing CMS claims data on all discharged patients. Some patients included in the initial cohort did not have CMS claims data as they were not Medicare beneficiaries. In addition, some Medicare plans are administered by commercial insurers and may not have been included in the claims database used for the hospital utilization analysis.

Our study is the first, to our knowledge, that characterizes and categorizes MRPs identified and resolved by a pharmacy team conducting telephonic post-discharge medication reconciliation. We were able to describe multiple interventions made and their potential impact using the Medication Therapy Intervention and Safety Documentation Program User Manual v 6.0 (Chen, 2011). Severity ratings of the MRPs were determined based on the class of medication involved, and, thus, the potential for patient harm. For example, problems with high-risk medications such as insulin, oral hypoglycemic medications, oral anticoagulants, and opioids were given greater severity ratings due to higher risk posed to patient safety. It is notable that some MRPs may actually produce harm greater than theoretically anticipated. Therefore, resolution of MRPs at the time of the telephone call has the potential to greatly affect patient safety and outcomes.

Some limitations of our program and study should be noted. There was a larger proportion of patients in the usual care group with an index discharge from inpatient hospitalization compared with those in the intervention group, suggesting greater acuity of illness in usual care group patients. There is also possible selection bias inherent to being able to reach a patient by telephone, and his or her willingness to participate in the phone call following hospitalization. Many of the patients (n = 558) did not receive a post-discharge phone call. This was largely related to limitations of time and clinical personnel to conduct post-discharge medication reconciliation on all hospitalized patients.

Our study highlights an opportunity for future research to focus on predictive strategies that can readily identify those patients most likely to benefit from post-discharge transitions of care services. Practices wishing to implement transitions of care programs similar to ours should identify the patients who may demonstrate higher risk of hospital utilization to improve feasibility of implementation. In addition, telephone contact can be difficult as we were unable to reach patients in approximately 40% of calls attempted due to issues such as wrong numbers and disconnected phones. Yet, these patients may be the ones who could benefit the most from such services. Practices interested in implementation of a similar service could mitigate this issue by continually updating alternative contact numbers and the names of emergency contact persons at every patient encounter. Health systems can also assist by ensuring the best contact information is included in the record at the time of hospital discharge.

As Medicare shifts focus to value-based care via the merit-based incentive payment system and advanced alternative payment models, clinicians should identify ways to improve quality of care while avoiding unnecessary costs (CMS, 2017). Similarly, coordinated care models, such as patient-centered medical homes and accountable care organizations, aim to improve patient outcomes while containing costs across the continuum of care. Transitional care services, which focus on medication reconciliation and resolution of MRPs, correspond with these aims. Such services can help reap financial benefits and even prevent readmission penalties (CMS, n.d.) Furthermore, revenue opportunities exist via Medicare transitional care management billing codes when patients are contacted via phone within 48 hr of hospital discharge, provided with medication reconciliation, and are seen by a provider within 7 or 14 days of hospital discharge (CMS, 2018). The model we have described is in accordance with the criteria necessary to participate in such Medicare programs.

We have described a model that not only highlights the benefits of telephonic post-discharge medication reconciliation by reducing total health care utilization and resolving MRPs but also aligns with evolving priorities of payers. As practices seek to adopt models of care that improve quality and contain costs, transitions of care programs such as the one described in this article can help accomplish these goals.

Footnotes

Acknowledgements

We would like to acknowledge the Lake Superior Quality Innovation Network in providing data analytics for this project. Analysis of claims data was conducted by Lake Superior Quality Innovation Network, under contract with the Centers for Medicare and Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy, 11SOW-MI-C3-18-57 030118. We would like to acknowledge the assistance of David Trupiano, PharmD, with data extraction from the electronic medical records.

Research Ethics

This study was approved by the Wayne State University Institutional Review Board (#089312MP4E).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Candice L. Garwood

References

Agency for Healthcare Research and Quality. (2012). Medications at Transitions and Clinical Handoffs (MATCH) toolkit for medication reconciliation. Retrieved from https://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/match/index.html

Agency for Healthcare Research and Quality. (2013). The patient centered medical home resource center. Retrieved from https://www.ahrq.gov/cpi/about/otherwebsites/pcmh.ahrq.gov/index.html

Al-Rashed

S. A.

Wright

D. J.

Roebuck

Sunter

Chrystyn

(2002). The value of inpatient pharmaceutical counselling to elderly patients prior to discharge. British Journal of Clinical Pharmacology, 54, 657-664.

Anderson

S. L.

Marrs

J. C.

Vande Griend

J. P.

Hanratty

(2013). Implementation of a clinical pharmacy specialist-managed telephonic hospital discharge follow-up program in a patient-centered medical home. Population Health Management, 16, 235-241.

Barnsteiner

J. H.

(2005). Medication reconciliation: Transfer of medication information across settings-keeping it free from error. American Journal of Nursing, 105, 31-36.

Brega

A. G.

Barnard

Mabachi

N. M.

Weiss

B. D.

DeWalt

D. A.

Brach

. . . West

D. R.

(2015). AHRQ health literacy universal precautions toolkit (2nd ed.). Rockville, MD: Agency for Healthcare Research and Quality.

Budiman

Snodgrass

Chang

A. K.

(2016). Evaluation of pharmacist medication education and post-discharge follow-up in reducing readmissions in patients with ST-Segment Elevation Myocardial Infarction (STEMI). The Annals of Pharmacotherapy, 50, 118-124.

Centers for Medicare and Medicaid Services. (2017). Quality payment program. Available from https://qpp.cms.gov

Centers for Medicare and Medicaid Services. (2018). Physician fee schedule care management. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/

10.

Centers for Medicare and Medicaid Services. (n.d.). Readmissions reduction program. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

11.

Chen

(2011). Medication therapy intervention & safety documentation program user manual (Version 6.0). School of Pharmacy, University of Southern California. Retrieved from careinnovations.org

12.

Coleman

E.A.

Boult

(2003). American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51(4), 556-7.

13.

Coleman

E. A.

Smith

J. D.

Raha

Min

S. J.

(2005). Post-hospital medication discrepancies: Prevalence and contributing factors. Archives of Internal Medicine, 165, 1842-1847.

14.

Crotty

Rowett

Spurling

Giles

L. C.

Phillips

P. A.

(2004). Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. The American Journal of Geriatric Pharmacotherapy, 2, 257-264.

15.

Dudas

Bookwalter

Kerr

K. M.

Pantilat

S. Z.

(2001). The impact of follow-up telephone calls to patients after hospitalization. The American Journal of Medicine, 111, 26S-30S.

16.

The Institute of Medicine. (1999). To err is human: Building a safer health system. Retrieved from http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf

17.

Kallenbach

L. R.

Smitherman

H. C.

(2012). Dying before their time II: The startling truth about senior mortality in the Detroit area and urban Michigan. Detroit Area Agency on Aging. Retrieved from http://www.mi-seniors.net/pdfs/publications/Dying%20Before%20Their%20Time%20II%20-%202012%20Final%20Report.pdf

18.

Lipton

H. L.

Bird

J. A.

(1994). The impact of clinical pharmacists’ consultations on geriatric patients’ compliance and medical care use: A randomized controlled trial. The Gerontologist, 34, 307-315.

19.

Nassaralla

C. L.

Naessens

J. M.

Chaudhry

Hansen

M. A.

Scheitel

S. M.

(2007). Implementation of a medication reconciliation process in an ambulatory internal medicine clinic. Quality and Safety in Health Care, 16, 90-94.

20.

Nazareth

Burton

Shulman

Smith

Haines

Timberal

(2001). A pharmacy discharge plan for hospitalized elderly patients: A randomized controlled trial. Age and Ageing, 30, 33-40.

21.

Nigro

S. C.

Garwood

C. L.

Berlie

Irons

Longyhore

McFarland

M. S.

. . . Trewet

C. B.

(2014). Clinical pharmacists as key members of the patient-centered medical home: An opinion statement of the ambulatory care practice and research network of the American College of Clinical Pharmacy. Pharmacotherapy, 34, 96-108.

22.

Schnipper

J. L.

Kirwin

J. L.

Cotugno

M. C.

Wahlstrom

S. A.

Brown

B. A

Tarvin

. . . Bates

D. W.

(2006). Role of pharmacist counseling in preventing adverse drug events after hospitalization. Archives of Internal Medicine, 166, 565-571.

23.

Smith

McGowan

Moss-Barclay

Wheater

Knass

Chrystyn

(1997). An investigation of hospital generated pharmaceutical care when patients are discharged home from hospital. British Journal of Clinical Pharmacology, 44, 163-165.

24.

Stranges

P. M.

Marshall

V. D.

Walker

P. C.

Hall

K. E.

Griffith

D. K.

Remington

(2015). A multidisciplinary intervention for reducing readmissions among older adults in a patient-centered medical home. The American Journal of Managed Care, 21, 106-113.

25.

Tang

Fujimoto

Karliner

(2014). Evaluation of a primary care-based post-discharge phone call program: Keeping the primary care practice at the center of post-hospitalization care transition. Journal of General Internal Medicine, 29, 1513-1518.

26.

Tedesco

G. W.

McConaha

J. L.

Skomo

M. L.

Higginbotham

S. K.

(2016). A pharmacist’s impact on 30-day readmission rates when compared to the current standard of care within a patient-centered medical home: A pilot study. Journal of Pharmacy Practice, 29, 368-373.

27.

Walker

P. C.

Bernstein

S. J.

Jones

J. N.

Piersma

Kim

H. W.

Regal

R. E.

. . . Flanders

S. A.

(2009). Impact of a pharmacist-facilitated hospital discharge program: A quasi-experimental study. Archives of Internal Medicine, 169, 2003-2010.