Table 1 PHARM-DC intervention components and categorization [18]

Pre-Discharge Intervention

Hospital day 1, or as soon as possible when the patient/caregiver are available to discuss medication issues

Confirm accuracy of admission medication reconciliation

1. Assess regimen appropriateness 2. Talk to inpatient team re: recommended changes

3. Consider trial off meds as inpatient

Discuss past side effects, ways to avoid or treat them

Address most critical barriers to adherence and intervene where possible

At-Discharge Intervention

Day of discharge

1. Discharge med rec, communicate with inpatient team to correct any discrepancies 2. Briefly review med changes with patient

Document and communicate recommended medication changes to PCP

Briefly discuss potential side effects, red flags for new meds, what to do if red flags occur

Post-Discharge Intervention

Phone call 1–3 days after discharge

1. Call pharmacy to ensure meds picked up, communicate discontinued medications

2. Call with patient: confirm patient’s regimen.

3.Communicate with PCP re: changes in regimen.

Call with patient: ask about any new side effects, red flags to watch for

1. Call with patient: picked up meds, taking meds. 2. Motivational interviewing.

3. Address other barriers to adherence. 4.Communicate with PCP: tasks done and to be done to improve adherence.