Action | Timing | Medication Reconciliation | Regimen Review/ Polypharmacy | Side Effect Mgmt. | Adherence |
---|---|---|---|---|---|
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. |