Post Discharge Management

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Post Discharge Programs/Transitional Care

MedicoRx Specialty Pharmacy Post-discharge Community-Based Intervention Program (PCIP)

Patients with complex care needs who require care across different health care settings are vulnerable to experiencing serious quality problems. A care transitions intervention designed to encourage patients and their caregivers to assert a more active role during care transitions may reduce re-hospitalization rates.

  • The PCIP ensures that all discharged patients who have received the PCIP understand how to take medications the “right way” in the days after discharge.
  • The PCIP reduces emergency department visits and readmissions.
  • Patients and families are highly satisfied with the care they receive when provided PCIP discharges.

MedicoRx Specialty and the Hospital/Facility will Identify Which Patients Should Receive the PCIP 

Even if the goal is to deliver the PCIP to all patients discharged from your hospital, it might make sense to roll out the implementation in phases. Based on the analysis of your hospital’s needs and the goals you have set, you might want to identify selected subsets of patients who will receive the PCIP. Possible target populations include:

  • Patients with conditions initially targeted by the Centers for Medicare & Medicaid Services (i.e., heart attack, pneumonia, and heart failure) for reduced funding if the hospital has excess readmissions.
  • Patients with diagnoses with 30-day re-hospitalization rates higher than the national average or higher than peer hospitals in your community.
  • Sites of care (floor or unit) or services within the hospital (e.g., surgery, dialysis, post-CABG) that have the highest readmission rates.

MedicoRx Specialty will assume a role of the Discharge Pharmacy Educator (DPE) and the Outpatient Pharmacy for Discharged High Risk Patients with the following responsibilities:

  1. Identify the correct medicines and a plan for the patient to obtain them. Review all medicine lists with the patient, including, when possible, the inpatient medicine list, the outpatient medicine list, as well as what the patient reports taking. Ascertain what vitamins, herbal medicines, or other dietary supplements the patient takes.
  1. Educate the patient about his or her diagnosis and medicines. Provide education on primary diagnosis and comorbidities. Explain what medicines to take, emphasizing any changes in the regimen. Review each medicine’s purpose and how to take each medicine correctly, and note important side effects. Assess patient’s concerns about the medicine plan.
  1. Confirm with the In-hospital Medical Team. Confirm the diagnosis, the medicine list for discharge and communicate discrepancies found. Gather information from the patient: list of the meds taken prior to admission, medicine allergies, record of adverse reactions and side effects.
  1. Identify the Correct Medicines and a Plan for the Patient To Obtain Them. Two of the most important components of the PCIP are to: (1) identify the correct medicines that the patient should take (and not take) after discharge, and (2) arrange for the patient to obtain the medicine.
    • The purpose of medicine reconciliation in preparation for hospital discharge is to determine that the patient’s discharge medicine list and discharge summary medicine list reflect the most recent and accurate updates made to the patient’s medicine plan. Obtain the current list of medicines from the outpatient medical record (when available), the inpatient chart, and in some cases, the patient’s local pharmacy records, to determine what medicines the patient has been taking. If no list is available, see if a family member can bring all the patient’s medicine containers to the hospital. Review the list when you first meet the patient to determine what he or she is taking.
    • Determine if the patient uses or plans to use any other types of treatments along with the medicines, such as herbs, dietary supplements, OTC meds. This can identify potential interactions with prescription medicines. Discuss any discrepancies with the medical team and identify what medicines the patients should and should not be taking. Before discharge, resolve all discrepancies discovered in the medicine list.
  1. DELIVER ALL MEDICATIONS TO THE PATIENT ON THE DAY OF DISCHARGE, either to the hospital at bedside or patient’s home. Medications will be packaged in the special way to increase compliance and adherence (see Appendix A).
  1. Teach About the Patient’s Medicines:
    • Any changes to medicines (new medicines, change in dose or frequency, etc.).
    • The correct dose.
    • The time of day to take them.
    • What to do if he or she misses a dose.
    • The reason he or she is to take them.
    • Which medicines to continue taking and which to stop taking.
    • How long to take it (even if symptoms go away).
    • Potential side effects.
    • Not to discontinue without calling the doctor (when appropriate).
    • The importance of bringing all medicines to follow-up appointments.
  1.  Assess the Degree of Patient Understanding.
  1. Provide Telephone Reinforcement of the Discharge Medications Plan.  The final component of the RED is to reinforce the discharge plan by calling the patient at home in the 2 or 3 days after discharge.  It will be an action-oriented call designed to identify problems or misunderstandings that have developed after discharge and to organize a pharmaceutical plan to address these issues.  Another follow-up call will be made 14 and 28 days after the discharge.

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