Care transitions service: a pharmacy-driven program for medication reconciliation through the continuum of care.

Purpose: A quality-improvement program at University of New Mexico Hospital (UNMH) encompassing admission, discharge, and postdischarge medication reconciliation activities is described, with a report on initial assessments of the program's impact on rates of medication-related problems (MRPs).

Methods: Pharmacists conducted a five-month evaluation of the UNMH Care Transitions Service (CTS), which serves inpatients admitted to the hospital's family medicine service, providing medication reconciliation and targeted MRP interventions. Selected patients who received CTS services from November 2012 through March 2013 (n = 191) were included in the analysis. The study endpoints were the rates and types of MRPs identified, the most commonly implicated medication classes, and predictors of MRPs. Postdischarge MRP rates during a two-month trial of CTS services at a UNMH outpatient clinic were also evaluated.

Results: During the five-month evaluation of inpatient CTS services, a total of 1140 MRPs were identified (an average of 6 per patient), about 70% of which were resolved independently of provider review using pharmacy-driven protocols. During the two-month pilot test of CTS outpatient services (n = 16), a total of 28 MRPs were identified; in over 80% of cases, there was a decline in the number of MRPs from the admission to the postdischarge medication reconciliation.

Conclusion: MRPs were identified through the continuum of care. The majority of MRPs identified in both the inpatient and outpatient settings involved patient variables and patient nonadherence. Seventy percent of inpatient MRPs were resolved independently by the CTS team under pharmacy-driven protocols.