1. Continuity of Care Components of a Meaningful Primary Care Visit
Pre-Visit
Visit
Post-Visit
Inter-Visit
Review notes – your last note, any notes by other MDs in the interim, ER or discharge summaries
Inform patient of their PCP and nurse – provide resources (business card and team photo composite)
Assign PCP in EMR
Complete timely DC summary including the PCP name and H & P.
Review interim labs
Review all meds (purpose, frequency, dose, other) with patient and give them a copy of the updated med list
Document diagnostic tests and studies ordered and pending (IP) and follow up on them
If patients’ meds change when admitted based on MUSC’s Automatic Therapeutic Substitution, change them back to patient’s insurance formulary at the time of discharge
Review interim studies – ex. mammogram, stress test, colonoscopy, etc.
Give the patient a medication bag and encourage taking it with them to all provider visits
Notify UIM PCP when seeing another provider’s patient by using the “.cc code.” (OP)
Visit or call the patient during hospitalization when notified of their admission
Review any consults
Look up provider codes in EMR through knowledge base.
Set up any needed health maintenance
Notify patient of test results

2. Medication Reconciliation Steps
Continuity of Care Patients 65 years and older have multiple medical problems, are on multiple medications, and are seen by multiple providers. Having a primary care physician, communicating among all providers, and reconciling medications are all essential for quality patient care.
Medication Reconciliation Steps
Ask the patient…
1. What are the names of the medications (including OTC, vitamins, herbal supplements and eye drops) you are currently taking?
2. How do you take your medications and how much have you been taking?
3. Do you understand what the medication is for?
4. Where do you get your prescriptions filled?
MD action…
1. Compare home list to the list in the patient’s chart.
2. Ensure dose and frequency are the same and there is a clear indication for every medication.
3. If patient doesn’t understand what meds are for, educate using plain, non-medical language; speak slowly; break down information into short statements.
4. Call the pharmacy if there is any discrepancy between the patients’ reported meds and your list. Rectify in the patient’s chart.
Obtain medication
list from patient
Obtain medical record
medication and
problem list
Identify discrepancies
Call pharmacy or call family
Enumerate all meds
Reconcile list
Consolidate meds
Evaluate ongoing need of each med.
Optimize the list
Incorporate into med list
Document updated
medication list
Give patient a copy of updated medication list
Include updated list in clinic note
Funding provided by D.W. Reynolds Foundation
References: Wenger, N.S. and R.T. Young (2007) “Quality Indicators for Continuity and Coordination of Care in Vulnerable Elders.” JAGS 55:S
Varkey, P. et al (2007) “Improving Medication Reconciliation in the Outpatient Setting.” Jt. Comm J on Quality & Patient Safety 33:5.