Health systems have a renewed interest in ensuring high quality of care provided in lower-cost, postacute care settings such as skilled nursing facilities, home care, and long-term care, and more effective collaboration is a critical component of this mission. Here are a few ways pharmacists can do their part to help improve postacute care coordination:
 
1. Perform medication reconciliation during all transitions of care. No one in any care facility is better trained to review medication lists and identify potential problems than the pharmacist. A prescription that may have been necessary at one stage of a patient’s care may not be necessary after a care transition. Failure to de-prescribe medications that are contributing to adverse effects can have serious consequences, including worsening of a disease state or increased mortality.
 
Medication reconciliation may be less likely to happen when a patient moves from a hospital to a postacute care facility because health care providers in one setting may assume that their counterparts in the next setting have or will perform the task. Pharmacists can help correct this problem by completing medication reconciliation across the care continuum to ensure effective patient transitions to and from postacute care facilities.
 
2. Track the patient’s postdischarge progress. The work of a hospital pharmacist isn’t finished once a patient has left the facility. Pharmacists can make follow-up calls to ensure that patients are taking their medications, as well as reduce adverse events. Through efforts targeting high-risk patients, one study found medication-related problems in more than half of the calls completed by the pharmacy. The postdischarge intervention helped decrease readmission rates by 50% among the study population.
 
Seena Haines, PharmD, BCACP, FAPhA, FASHP, BC-ADM, CDE, told Pharmacy Times that a successful postdischarge process for patients with diabetes relies on setting clear, timely goals.
For example, in patients with diabetes, “[The goals] are really centered on behavioral changes,” she explained. “We want to work in concert with them to establish what those steps will be.” Most importantly, she said, is ensuring that patients can actually attain the goals. “We have to be careful to not set a goal that is unrealistic for the patient,” she said. “Motivational interviewing helps develop smart goals and determine what the patient is willing to do. Self-management is key.”
 
3. Leverage health information technology (HIT).One of the biggest trends in health care is the rise of value-based payment models, such as accountable care organizations (ACOs).
 
As HIT, exchange capabilities, and care models mature, pharmacists have access to more and more data. This enables them to provide more advanced patient care services, such medication therapy management (MTM), and really start to drive value.
 
According to the Office of the National Coordinator, HIT is defined as the application of information processing involving computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision-making.
 
Pharmacists are taking on a more expanded and active role as key members of the patient care team in ACOs, and their efforts are facilitated by HIT. As a clinical expert working on an interdisciplinary team, for example, the pharmacist can use HIT to help with medication reconciliation and optimize MTM during transitions of care between a hospital and a postacute care facility.
 
4. Address any communication barriers head on. Pharmacists should be proactive about reconciling any communication barriers they see among themselves, prescribers, and all other health care providers in the postacute care setting.
 
Communication barriers that can hinder pharmacists’ efforts include the following:
· Lack of interprofessional training
· Multiple prescribers, especially when handling patients with multiple comorbidities
· Drug interaction misconceptions
· Relaying messages through receptionists
· Lack of availability to speak with prescribers
· Overwhelming patient volume
 
Recognizing and addressing these common problems will inevitably improve overall patient care.

Watch Dr. Haines describe how health-system pharmacists can optimize their role in diabetes care at pharmacytimes.com/conferences/ashp-summer-2016.