Hospital pharmacists take the lead in discharge counseling


Adding pharmacists to the hospital discharge process is shown to have a positive effect on combating hospital readmission rates

A unique opportunity

Although there are many reasons for hospital admissions, often they are the result of drug-related problems (DRPs). These problems may result in treatment failures and/or adverse events. DRPs are more common after hospitalization as a result of errors in medication reconciliation and lack of education.1,2 As healthcare professionals, pharmacists have a unique opportunity to minimize the evolving problem of DRPs. We have the knowledge and resources to properly educate patients on their medications and disease state management, which has been the focus of several studies.3,4


In 2002, Medicare and the Agency for Healthcare Research and Quality began work on the development of the first standardized and nationwide survey to measure patients' hospital experiences.5

In 2005, a survey was created to measure patients' perspectives on their hospital care: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The HCAHPS is a national standardized survey comprising 27 questions about the patient's hospital experience.5,6

Recently, the HCAHPS scores have become even more important, as the Centers for Medicare and Medicaid Services (CMS) has decided to base hospital reimbursement on HCAHPS scores beginning in 2013.5,6

As pharmacists, we have a duty to open the door to communications about medication. We have the ability to help increase our institution's scores by educating our patients as well as improve patient care and the overall hospital experience.

Medication education is one of the most important roles of a pharmacist. Interacting with patients, however, takes place most often in the community setting. For decades, it has been the responsibility of the community pharmacist to educate patients on medication therapy.

In July 2011, South Pointe Hospital in Warrensville Heights, Ohio, implemented a decentralized practice model. Each day, a pharmacist identifies which patients are ready for discharge on his/her assigned floor. Each patient's medications are reviewed, and the pharmacist notifies the physicians of drug therapy recommendations. Finally, before the patient is discharged, a pharmacist meets with the patient to provide medication education. This meeting gives the patient an opportunity to have his or her questions answered and concerns addressed.

The pharmacist begins by performing a Drug Utilization Review (DUR), monitoring for drug duplications, drug interactions, and correct drug therapy for each disease state. Once the pharmacist and physician approve the medication list, the pharmacist meets with the patient.

The pharmacist will educate the patient about his or her disease state and explain the purpose of each medication. The pharmacist will describe how and when the patient should take each drug. If needed, the pharmacist will help the patient divide the medications into a pillbox, and then the patient can ask questions.

Each discharge education session lasts around 30 minutes and does not conclude until the patient fully understands the drug therapy regimen and is fully confident about being able to follow it.

Once the patient confirms understanding, the pharmacist hands the patient any new prescriptions to have filled upon arrival at home.

The pharmacist may also call the prescription into a specific pharmacy at the patient's request, or set up the patient's mail order prescriptions as an additional convenience.

The patient is then given the pharmacist's business card, in case a question should arise after the patient arrives at home.

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