Conferences WPQC The Journal

Follow-up Communication Resources

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

Guideline Statements 

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


Toolkit Table of Contents

PSW Transitions of Care ToolkitPSW Transitions of Care Toolkit

PSW Transitions of Care Toolkit

Business Case ResourcesBusiness Case Resources

Business Case Resources

Discharge Medication ReconciliationDischarge Medication Reconciliation

Discharge Medication Reconciliation

Discharge Patient EducationDischarge Patient Education

Discharge Patient Education

Discharge Prescription ManagementDischarge Prescription Management

Discharge Prescription Management

Follow-up CommunicationFollow-up Communication

Follow-up Communication

Pharmacy Hand off CommunicationPharmacy Hand off Communication

Pharmacy Hand off Communication



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