2. Intervention Design and Target Patients

Intervention components before and after implementation

According to Qualitativearticle_82373639, the hospital implemented a team-based pharmacy practice model designed to strengthen medication management across hospitalization and discharge. Pharmacy teams included attending pharmacists, residents, and students, and they provided daily comprehensive medication review, therapy interventions for drug-related problems, and protocol-based dosing management.

Before implementation, the pharmacy service did not yet have the full hospitalwide transition-focused structure evaluated in the study. After implementation, the model emphasized several core activities across the patient stay:

• Medication reconciliation at transitions of care.
• Daily comprehensive medication review.
• Pharmacy-to-dose medication management under protocol.
• Discharge counseling for high-risk patients.

Qualitativearticle_82373639 explains that the evaluated model was intended to be sustainable rather than a temporary pilot. The article also notes that pharmacy teams achieved high rates of medication reconciliation at transitions of care and discharge counseling for high-risk patients, although discharge medication reconciliation and education were harder to complete consistently because of staffing limits, discharge timing, and communication barriers.

How high-risk patients were defined

In Qualitativearticle_82373639, high-risk patients were identified by specific clinical criteria. Patients were considered high risk if they:

• Were admitted with acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia, based on CMS core-measure criteria.
• Had chronic obstructive pulmonary disease (COPD) as the primary reason for admission.
• Were discharged on oral anticoagulation therapy, specifically warfarin, dabigatran, or rivaroxaban.

The source also states that patients on oral anticoagulation could belong to an additional high-risk category if they also met one of the admission-based criteria above. Patients who met the study inclusion criteria but none of these high-risk definitions were placed in the non-high-risk group.

High-risk patients were manually identified by pharmacy team members during profile review. The need for discharge education was then documented in the electronic medical record pharmacy notes area to support pharmacist handoff communication.

Pharmacy activities prioritized at transitions of care and discharge

Qualitativearticle_82373639 makes clear that the pharmacy service prioritized a small set of activities believed to be most important for safe transitions and discharge.

At transitions of care, the main priorities were:

• Medication reconciliation whenever patients moved between care settings or levels of care.
• Comprehensive review of the medication regimen to identify drug-related problems.
• Protocol-based medication dosing and management for selected therapies.

At discharge, the main priorities were:

• Discharge medication reconciliation.
• Patient education and discharge counseling, especially for high-risk patients.

The article further emphasizes that an adequately staffed pharmacy team should be able to provide these critical interventions for all patients, while giving special discharge attention to those at highest risk. In practice, the discharge-related tasks were more difficult to complete than admission reconciliation because qualified staff might not be available, the pharmacy team was not always informed promptly of discharge plans, and patients sometimes left soon after the discharge decision was made.

Summary

In summary, Qualitativearticle_82373639 describes a hospitalwide, sustainable pharmacy practice model that expanded pharmacist involvement in medication reconciliation, medication review, dosing management, and discharge counseling. High-risk patients were defined mainly by selected diagnoses and oral anticoagulation at discharge. The most strongly prioritized pharmacy activities were medication reconciliation at transitions of care and discharge counseling for high-risk patients, supported by ongoing medication review throughout hospitalization.