Design and implementation of a targeted approach for pharmacist-mediated medication management at care transitions.

Objectives: 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.

Setting: Minneapolis Veterans Affairs (VA) Health Care System from December 1, 2014, to April 1, 2015.

Practice Description: 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.

Practice Innovation: 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.

Interventions: High-risk patients engaged in comprehensive medication therapy management appointments performed by primary care clinical pharmacists with an independent scope of practice.

Evaluation: 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.

Results: 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.

Conclusion: Stratification of patients and pharmacist-mediated MTM appointments resulted in the identification and resolution of medication-related problems and drug discrepancies at care transitions.