![]() The inpatient medical or nursing team referred their patients who were eligible for the program. This program targeted clinically complex children, as defined by patients who 1) required 3 or more follow-up appointments after discharge, 2) were on complex medication regimens as determined by their provider, and/or 3) were clinically and/or psychosocially complex as determined by their provider. This patient navigation program was created at a freestanding pediatric hospital licensed for 250 beds to address some of the barriers associated with providing successful discharge care. Therefore, this project aims to implement a transition of care program to improve the discharge process within a pediatric setting.īackground. 14 However, there is limited published literature regarding pediatric transition of care programs. 3–5, 11–13 Furthermore, initiatives to improve medication adherence may improve important clinical outcomes, such as readmission rates. Pharmacists working collaboratively with existing health care teams can help improve patient outcomes through medication reconciliation and medication counseling. 8–10 Several of these transition of care programs use pharmacists to optimize medication therapy and identify areas of potential medication safety concerns. Studies have shown that the use of these navigators, who work to provide services such as increasing outpatient follow-up appointments and identifying medication discrepancies, can improve transitions of care. To improve the discharge planning process, several hospitals have implemented programs in which patient navigators provide resources to guide patients through the discharge process. This program resulted in an estimated cost savings of $22,308 in the first 5 months.ĬONCLUSIONS A unique partnership between nurses and pharmacists facilitated the discharge process for clinically complex children. ![]() The most frequently identified interventions included clarification of drug order, assistance obtaining medication, and dose rounding. Pharmacists identified 168 interventions, of which 93.5% were accepted or informational in nature. ![]() Patients who were provided pharmacy services had a median of 8 comorbidities, 10-day length of stay, and 4 discharge medications. A pharmacist was able to provide discharge counseling for 56 discharges (17%). RESULTS There were 321 patient navigation referrals during the 5 months of pharmacist service. Financial benefit gained from the program was estimated by translating each pharmaceutical intervention into potential cost savings. Program utilization was measured by the number of referrals received, percentage of patients seen by a pharmacist, follow-up phone call completion rate, and pharmacist time required. The impact on patient outcomes was measured by the number and type of pharmacist interventions identified. Patient demographics, admitting diagnosis, and number of discharge medications were recorded. METHODS For select patients referred to the service, a pharmacist resolved medication discrepancies, provided discharge counseling, and conducted follow-up telephone encounters on days 1, 7, and 14 post discharge. The purpose of this project was to add pharmacy discharge services to an existing nurse-led discharge service (patient navigation program) to facilitate the transition of care process for clinically complex pediatric patients. OBJECTIVES Numerous challenges face clinically complex patients as they transition from hospital to home.
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