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

Abstract

ObjectivesTo 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. SettingMinneapolis Veterans Affairs (VA) Health Care System from December 1, 2014, to April 1, 2015. Practice descriptionA 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 innovationPharmacists 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. InterventionsHigh-risk patients engaged in comprehensive medication therapy management appointments performed by primary care clinical pharmacists with an independent scope of practice. EvaluationMedication-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. ResultsA 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. ConclusionStratification of patients and pharmacist-mediated MTM appointments resulted in the identification and resolution of medication-related problems and drug discrepancies at care transitions.