Abstract
This paper describes a proactive, patient-centered, interprofessional approach to medication review in a long-term care facility. Clinical pharmacy services were provided to residents in multiple high-risk areas including transition of care; medication reconciliation; monitoring of infectious disease, pain, anticoagulation, psychotropic drugs, and falls; and requested consults for any change in condition. Process outcomes were evaluated, specifically the number of patients reviewed, number and type of recommendations made, and acceptance rate of recommendations by physicians; 1,333 medication regimen reviews were conducted. A total of 274 recommendations were made, and 56 recommendations were excluded as "lost to follow-up" because the recommendation was not acknowledged by the physician. Of the 218 acknowledged recommendations, 157 (72%) were accepted. Collective workload statistics suggest that the service identified and eliminated potential drugrelated problems such as inappropriate medications, drug interactions, and discrepancies during medication reconciliation. The large number of reviews conducted in a short time period show that there is a need for regular pharmacist review.
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