UAMC –
Discharge Medication
Optimization
Lauren Miller, PharmD.
Instructor
University of Arizona College of Pharmacy
Clinical Staff Pharmacist
Ambulatory Services, UAMC Hospital
Pharmacist Pilot Program:
From Discharge to the First Refill
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One full time pharmacist
2 inpatient units
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focused on discharges only
Attend daily care coordination meetings on each
floor with nurses, case managers, and social
workers to identify high risk patients and plan
safe discharges from admission
Responsibilities
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Review discharge medication orders
Duplicates
 DDI
 Missing medications or prescriptions
 Remove unnecessary meds
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Coordinate prior authorizations ahead of time
and assist patients unable to afford meds
Assist patients to fill at hospital pharmacy so
they can leave with all new medications
Counsel on medications and education on
disease states at bedside
What has worked….
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Team based transitions of care with nurses, case
managers, social workers, and MD all involved
All members of the above team now rely on me
to assist more difficult discharges and alert me to
patients who need my assistance
Good response from patients who like getting
their medication problems resolved prior to
discharge
Challenges
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How to determine when discharge order is in
Subscribe to discharge pager for both units
 Have nurses contact me
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Have to wait until discharge is finalized to
review meds for accuracy
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Multiple patients can be discharged at the same time
how to see all of them
Getting MDs on board with new program
Examples of Errors Caught
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Numerous DDI when home meds restarted
Discharges with duplicate meds
Patients discharged without scripts for new meds
New diabetics leaving without Rx for meters or syringes
Patients leaving without INR follow-up for new start
coumadin
Provide assistance to patients unable to afford or changing
to meds patients can afford
Incorrect dosing on discharge meds
Data Being Collected
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Number of patients interacting with discharge
pharmacist including:
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Number of meds counseled on
Type of error that was caught and class of medication
If insurance authorization was needed
Amount of time spent on each discharge
Readmission rates before and after
HCAHPS scores
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Patients ranking of communication about medications (from
hospital survey after discharge)