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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

References can be found here.