Leticia (Tish) Moczygemba, PharmD, PhD, associate professor at the University of Texas College of Pharmacy, knew that medication reconciliation during a transition of care was not always performed, or when completed, could be inadequate.  
 
Moczygemba was familiar with the Community Pharmacy Foundation (CPF) and thought a collaboration could be beneficial. She teamed up with colleague Rannon Ching, PharmD, pharmacist-in-charge at Tarrytown Pharmacy in Austin, Texas, to solidify the project’s details and apply for a CPF grant. 
 
Moczygemba and Ching’s goal was to implement enhanced medication reconciliation for patients who were being discharged from the hospital back to their senior living facility. Tarrytown Pharmacy had a 35-year relationship with a nearby facility, a perfect opportunity for a meaningful partnership.
 
“It’s a common problem in community pharmacy,” Ching said. “You have a recently discharged patient and they walk up to the counter with a huge stack of discharge paperwork. They’ve been going to their family doctor for years, and their hospital doctor changed everything. There’s a lot of confusion.”
 
The initial goal was to implement enhanced medication reconciliation and, by doing so, limit adverse drug events and hospital readmissions. 
 
The pharmacy used a teamwork approach, as Ching met with the team at the assisted living facility to establish interest and form a plan. The facility knew that it would be helpful to have pharmacists as part of the team. 
 
Moczygemba and Ching also knew that it was important to notify and educate the residents of the facility. The pharmacists placed a flyer in every resident’s mailbox, explaining the process, so the residents knew that pharmacists would be part of the transition of care process.

“It was important and appreciated,” Ching said. “The residents knew we weren’t trying to sell them something.”
 
A nurse at the assisted living facility would notify Ching when a patient was admitted to the hospital and the anticipated discharge date. The pharmacists followed Medicare guidelines on how to do a billable visit. 
 
“We had 48 hours from discharge to contact the patient and set up a meeting,” Ching said.

Due to the patient education and nurse involvement, the patients were expecting the call and were very receptive to the program. A trained pharmacy technician called the patient to go through a questionnaire to perform basic medication reconciliation, look for red flags—such as taking an opioid, diabetes medication, or anticoagulant, which would need to be addressed quickly—and schedule a face-to-face visit with the pharmacist. 
 
Moczygemba stressed the importance of team involvement and using time efficiently.

“If you don’t use technicians for this, it would be impossible,” Ching said. “Our technicians are there to help. They did a great job on the initial outreach and 21-day follow-up call.” 
 
Next, Ching or his resident would go to the facility and meet with the patient for 30 to 60 minutes for a more thorough counseling session.

“We were able to do a true medication reconciliation. The patients would bring their medications, and we found a lot of discrepancies from what they said on the phone,” Ching said.

They also discussed why the patient went to the hospital. Ching provided the patient with an updated medication list and provided some tips on avoiding readmission.

Take homes to stay home.” For example, a patient with congestive heart failure should monitor their weight. The pharmacy technician called patients on day 21 to follow up. 
 
In terms of results, the pharmacists were able to make considerable strides in helping their patients. Ching found that patients needed more education on what to expect regarding adverse effects with new medications, such as orthostatic hypotension from blood pressure medication or bleeding from anticoagulants.
 
Ching recalls a patient who told him that she was so lethargic all the time that she couldn’t enjoy life and didn’t want to live anymore.

“I had to counsel her, let her know she just started a new blood pressure medication, and it may take some time to adjust,” Ching said.

On the follow-up call, the grateful patient told Ching she adjusted to the medication and was feeling great.

“Sometimes patients just need hope, and reassurance that they’re on the right track, otherwise they may just stop taking their medication and be right back where they started,” Ching said.
 
Although Moczygemba and Ching encountered an obstacle with the billing model due to a leadership change at the facility, they recommend persistence. A partnership with a physician or facility and billing Medicare, for example, could be a path to explore.

“It’s important to keep pushing for provider status so that we can truly offer the complete service and get reimbursed properly,” Ching said.
 
In practice, what can pharmacists do with such limited time, especially in the chaos of a busy chain setting?

“Listen to the patient, really hear their concerns,” Ching said. “Talk to them about their concerns. Counseling is not a 1-way street, it’s about listening to what is on their minds.” 
 
Moczygemba and Ching suggest a call to action for pharmacists—be persistent, keep going, engage your whole team, and get out in the community to build partnerships and find opportunities. Be collaborative and creative, and be innovative in getting around roadblocks.

“Don’t let a roadblock deter you, find a new path to go around,” Ching said. 
 
Tarrytown Pharmacy is also part of CPESN and Flip the Pharmacy. The Community Pharmacy Foundation, led by Executive Director Anne Marie (Sesti) Kondic, PharmD, is a non-profit organization dedicated to advancing community pharmacy practice and patient care delivery through grant funding and resource sharing.