Follow-up services are opportunities where the patient still has direct access to his or her health care team post-discharge or other transition in care. Follow-up services are generally provided via appointment or telecommunications.
Corresponding PPMI Recommendations
- B22: Pharmacists should facilitate medication-related continuity of care
Wisconsin Transitions of Care Survey Results
- 44% of sites are interested in implementing post-discharge patient (medication) follow-up
- 40.3% of sites already provide post-discharge medication follow-up services
- 52% of sites document these communications in the electronic medical record and 40% directly send the communication to a primary care physician
ACCP Improving Care Transitions: Current Practice and Future Opportunities for Pharmacists
- For patients residing in assisted living facilities, post-discharge management should include monthly medication reconciliation and review. This should also include an assessment of whether or not a patient is able to safety self-administer medications.
- For patients discharged to the long term care setting, medication reconciliation services should be provided by a consultant pharmacist within five days of readmission to the long term care facility after a hospitalization or dramatic change in health status. The consultation should include family members.
ASHP-APhA Medication Management in Care Transitions Best Practices
Comprehensive patient-centered post-discharge follow-up programs should include:
- An interdisciplinary team partnership within the organization for joint follow-up
- Post-discharge follow-up calls by either the discharging inpatient pharmacist, an outpatient pharmacist, or pharmacy technician for triage within 72 hours of hospital discharge and again 30 days after discharge
- Patients who are at a high risk for readmission
- An assessment of any new medication related problems that may have arisen since discharge
- A review of the patient’s follow-up appointments and care instructions
- Adherence assessment
- Promotion of health care and medication access through community assistance programs and resources
- Collaboration of the inpatient and outpatient pharmacist on determination of the patient’s medication management needs
- Adequate documentation of the encounter
- A summary of findings and recommendations from all encounters should be communicated to the primary care physician and a reconciled list faxed to the community pharmacy