Review of a pharmacist discharge medication reconciliation program: characterization of medication discrepancies and prescriber follow up in patients with and without recent hospital admission Brittany Reynolds, PharmD Candidate, Trista Pfeiffenberger PharmD, Monique Alford, PharmD Add map, add med rec pic, flow diagram of med rec, little copy of the poster Move risk factors into background section below) Move objective and patients to middle colume. Combine patient population and methods Number and add references to picture Delete hospital patient records BACKGROUND OBJECTIVES DATA COLLECTION FORM Compare medication discrepancies identified and prescriber follow up received in patients admitted for the first time versus readmitted patients, both of whom receive discharge medication reconciliation services by a hospital based pharmacist.  Compare medication discrepancies by high risk status of the drug, discrepancy type, and urgency.  Contrast first time admissions against readmissions for discharge diagnosis, total number of medications, comorbid conditions, and other demographic variables.  Community Care of North Carolina (CCNC) is a group of nurse case managers and pharmacists who work with primary care providers (PCPs) as part of patient centered medical homes.  AccessCare is a network of CCNC which covers 24 of North Carolina’s 100 counties.  One component of AccessCare’s Transitional Care program involves a pharmacist conducting reconciliation and clinical review of medications on eligible hospitalized patients both during the hospital stay and at the time of discharge.  PATIENT DEMOGRAPHICS Patient Identifier: Age: Patient’s first admission within last 6 mos? Yes No Length of Stay: _______ days Aged, Blind, Disabled status? Yes No Dual eligible? Yes No Case Management Status: Medium Heavy Deferred Pending Primary Discharge Diagnosis From Current Admission: _________________________ Co-morbid Conditions:  ADHD/ADD  Anxiety  Asthma  Bipolar  Blood/Blood forming organs  Cancer  Cerebrovascular/CVA  CHF  Chronic Pain  CKD  COPD  CVD  Depression  Diabetes  Endocrine/Metabolic  Genital/Urinary  GI  HTN/CVD  ID/Parasitic Dx  Liver  Muscular/Skeletal  Nervous System  Psychosis  PTSD  Respiratory  Schizophrenia  Skin Diseases Previous admissions in last 6 months: Date:__________________ Primary Discharge Diagnosis:____________________________ Total Number of Medications: ________________________ MEDICATION DISCREPANCIES Discrepant Drug Name High Risk Medication? Discrepancy Type (#) Urgency Timing Yes No Urgent Non-urgent Pre-hospital During/Post-hospital Unknown PROVIDER RECOMMENDATIONS AND FOLLOW UP Recommendation(s) sent to: Hospitalist PCP Follow-up from PCP:  Received; accepted ____/_____ recommendations No follow-up documented Follow-up from Hospitalist:  Received; accepted ____/_____ recommendations DISCREPANCY IDENTIFICATION KEY Discontinued medication per discharge instructions, but still taking Not taking prescribed discharge medications Poor adherence to chronic medication (pre-hospital visit) Medications dose/frequency/duration Potential transcription error, combo drug, misnaming 6. Absolute contraindication (Drug-drug, drug-dz, drug-food) 7. Interaction non-absolute (Drug-drug, drug-dz, drug-food) 8. Adverse event/side effect reported 9. Drug allergy 10. Therapeutic duplication 11. Unconfirmed discontinuation 12. Unreported medications METHODS RISK FACTORS FOR READMISSION Inclusion: Medicaid or dually eligible Medicare/Medicaid patients who received inpatient and discharge reconciliation services by an AccessCare pharmacist on or after July 1, 2010. Methods: Data will be collected from the following sources NC Medicaid claims information CCNC case management information system CCNC medication reconciliation documentation form Documentation of communication between AccessCare pharmacist and hospitalist or PCP. Analysis: Descriptive statistics will be used to compare the characteristics of patients with their first admission against patients with a previous admission in a six month period. Readmission Early Hospital Discharge2 Therapeutic Error1,2 Adverse Drug Effects1,2 Inadequate Follow Up3 Disease Progression