• Luiza Kerstenetzky, Kristina M Heimerl, Katherine J Hartkopf, and David R Hager.
• J Am Pharm Assoc (2003). 2018 Sep 1; 58 (5): 540-546.

ObjectivesTo evaluate the impact of a pharmacist screening and automated referral process that identifies patients at risk for readmission due to medication-related problems (MRPs).SettingUniversity of Wisconsin (UW) Hospital is 505-bed flagship hospital that is part of UW Health, an academic health system.Practice DescriptionThe integrated pharmacy practice model at UW Health has inpatient pharmacists who perform discharge medication reconciliation. Before enhancing the screening and referral process, a transitions-of-care (TOC) pharmacist identified patients with the use of a low yield report and performed a second postdischarge medication reconciliation on selected patients.Practice InnovationA screening process was developed to identify patients at risk for readmission due to MRPs and allow for direct referral from inpatient pharmacists to a TOC pharmacist for postdischarge follow-up.EvaluationPatient characteristics, readmission risk, and readmission rate were compared between inpatient only (before referral) and inpatient plus second medication reconciliation (after referral). MRPs identified during medication reconciliation were quantified and categorized as provider or patient-associated.ResultsBefore process improvement, 9 patients (5%) received a second medication reconciliation out of 175 patients who received standard-of-care inpatient medication reconcilation. After implementation, 45 patients (24%) received a second medication reconcilation out of 188 referrals. Patients referred for postdischarge follow-up with the TOC pharmacist had an average of 3.2 more medications and 2.7 more chronic conditions than before process implementation (P < 0.01). Both inpatient and TOC pharmacists identified at least 1 MRP in about two-thirds of patients (P = 0.60). Provider-associated MRPs were more commonly identified in both inpatient and postdischarge settings.ConclusionInpatient pharmacist screening is an effective method for identifying patients for referral to a TOC pharmacist to receive postdischarge follow-up. Despite the robustness of the inpatient medication reconciliation process in identifying provider-associated MRPs, patient-associated MRPs still emerged after discharge that warranted additional pharmacist intervention.Copyright © 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

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