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Toolkit: Transitions of Care Management Cinical Resources & Documentation

Visiting Pharmacies After Discharge: High Risk Conditions:

The readmissions reduction program (HRRP; https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html) through the Centers for Medicare & Medicaid Services (CMS) have identified certain patients with high risk conditions to be targeted for improvements in readmission rates.  Among these are acute myocardial infarction (aMI), chronic obstructive pulmonary disease (COPD), heart failure (HF) and pneumonia.  Below are some overview documents on these conditions along with example documentation forms for patients with specified conditions visiting pharmacies after discharge.


Heart Failure

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Pharmacist HF Documentation Tool



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Pharmacist aMI Documentation Tool



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Pharmacist COPD Documentation Tool



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Pharmacist Pneumonia Documentation Tool



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Pharmacist Diabetes Documentation Tool


Medication-Related Errors and Issues

In addition to conditions, patients leaving the hospital are prone to other medication-related errors and issues including not obtaining their initial medication fills, discontinuing medications that they used to take (including discontinuing in the pharmacy dispensing record), and taking their medications as prescribed and following-up with non-pharmacologic recommendations and appointments after discharge.  The following guidance documents help to highlight some other common issues that pharmacists can assist with transitional care patients:


Medication Adherence

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Medication Reconciliation

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Teach Back

Providing information to patients about medications is a fundamental component of counseling, but it alone does not ensure patient's understand/comprehend the information provided.  Using the teach-back method helps to verify that patients and/or caregivers are understanding the important concepts you are trying to convey.  Before completing a counseling session, make sure your patients or caregivers know their material by asking them to share what they know.  Some examples of how to ask this to patients in a confident , considerate and complete manner are provided in this short overview from the North Carolina Program on Health Literacy.

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Transitions Information for Pharmacists

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Communication to Patients

Following up with patients and/or caregivers within the first week following discharge in person or by phone is important. Communicating with patients/caregivers about their care may be challenging at first.  Here are some principles of communication and examples of how to start the conversation when following-up with discharge patients. [disclaimer: The examples herein are intended to be used as a resource for communication and not as a verbatim supplement to the pharmacist's method of communication]

Example Community Pharmacy Visit Communication


Patient Assistance Program

Some patients may have trouble affording the medications they need. The NeedyMeds website has information on patient assistance programs along with coupons, rebates and other helpful resources.

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