(19.06) Effect of Pharmacy-Supported Transition-of-Care Interventions on Discharge Medication Reconciliation (DMR) Discrepancies in Patients with High-Risk/High-Cost Medications

The Joint Commission emphasizes medication reconciliations under National Patient Safety Goal 03.06.01, as discrepancies can negatively impact patient outcomes. Our novel transitions of care service sought to overcome barriers in access to and education of high-cost/high-risk medications (HCHRMs: anticoagulant, insulin, empagliflozin, sacubitril-valsartan, and/or inhalers) in patients through discharge medication reviews (DMRs) and medication education.

Methods:

This retrospective observational cohort study aimed to examine the impact of our service from October 1, 2022 to September 30, 2023. This was implemented for adult patients discharged on ≥1 HCHRM from a 627-bed public urban teaching hospital in Brooklyn, New York. The clinical pharmacists identified patients by rounding and reviewing patients on the medicine units daily. While patients were inpatient prior to discharge, the pharmacists provided medication education, conducted daily medication reviews, and obtained prior authorizations as necessary. The primary outcome was the percentage of patients discharged on ≥1 HCHRM with a DMR and education session. Secondary outcomes were the number of discrepancies, prior authorizations completed, and 30-day readmissions.

Results:

Prior to starting our service, 0% of patients discharged on a HCHRM had a DMR. Within a 1-year span since the program, the following percentages of patients discharged on a HCHRM had a DMR and counseling session: Q4 2022 (103/455; 23%), Q1 2023 (122/494; 25%), Q2 2023 (152/499; 30%), Q3 2023 (105/473; 22%). The following number of discrepancies total and per patient, respectively, were resolved: Q4 2022 (59; 1.8), Q1 2023 (65; 1.3), Q2 2023 (78; 1.5), Q3 2023 (44; 1.3). In Q4 2022, 19 prior authorizations were completed, which was approximately the same in Q1 2023, during which 20 were completed. Readmission rates within 30 days from Q4 2022 to Q3 2023 were 5%, 7%, 4%, and 2% per respective quarter.

Discussion/Conclusion: Since our unique transitions of care service was implemented, over the span of 4 quarters, an average of 25% of patients discharged on a HCHRM had a DMR and counseling session conducted by a pharmacist with an average of 1.5 medication discrepancies per patient. The number of prior authorizations were no longer tracked after Q1 2023 due to the New York Medicaid merge, which reduced the prior authorizations needed. Readmission rates within 30 days have decreased overall from Q4 2022 to Q3 2023. The results of our service demonstrated that clinical pharmacists are essential in optimizing the use of HCHRM by bridging gaps in prescribing and education between the inpatient and outpatient settings.