CHPPC Module 15, Section 3: Discharge Simplification & Reconciliation
MODULE 15: TRANSITIONS OF CARE & DISCHARGE MED REC

Section 3: Discharge Simplification & Reconciliation

This section focuses on the final and perhaps most crucial handoff in a patient’s journey: the transition from the highly structured inpatient world back to the community. An accurate medication history on admission prevents errors during the hospital stay; a meticulously planned discharge prevents readmissions and post-discharge harm. Here, you will learn the art of creating a safe, effective, and comprehensible discharge medication regimen. We will cover the forensic process of final reconciliation, explore powerful strategies for simplifying complex regimens and deprescribing unnecessary drugs, and ensure every plan is flawless before the patient leaves the building.

3.1 The Discharge Reconciliation: A Forensic Review of Intent

Beyond the list: Understanding the “why” behind every medication decision.

The discharge reconciliation is the cognitive apex of the transitions of care process. It is a forensic investigation into therapeutic intent. Your task is not merely to create a list of medications the patient should take. Your task is to ensure that this final list is the perfect, intentional synthesis of the patient’s pre-admission regimen and all the therapeutic changes made during their hospital stay. This process is profoundly complex and fraught with potential for error. Was a home medication held for a reason that is now resolved? Was a new hospital medication intended to be temporary or permanent? Answering these questions incorrectly can lead to disastrous outcomes. As the pharmacist, you are the final checkpoint, responsible for ensuring every medication on that final list is there for a clear, documented, and appropriate reason.

Retail Pharmacist Analogy: The Post-Vacation MTM Follow-Up

A longtime patient with complex diabetes and hypertension returns from a month-long trip where they saw multiple urgent care clinics for various issues. They come to your pharmacy with a bag of new pill bottles and a handful of scribbled notes. They are utterly confused about what they should be taking now. Your job is not just to fill new prescriptions; it’s to perform a comprehensive reconciliation. You line up their old, pre-vacation profile next to the new prescriptions. You identify the duplications (a new HCTZ from an urgent care, even though they are already on a combo pill) and the omissions (they ran out of their statin and forgot to get a new script). You call their PCP to adjudicate the conflicts and create a single, unified, up-to-date medication list. You are restoring order from chaos.

The hospital stay is the patient’s “vacation.” Multiple specialists (“urgent care clinics”) have added, stopped, and changed medications. The patient is confused. Your discharge reconciliation is that same process of taking the pre-admission list, comparing it to the current inpatient list, and forensically determining the single, correct, intentional regimen for the patient to follow moving forward.

3.1.1 The Three Lists: A Triangulation of Truth

A successful discharge reconciliation requires the systematic comparison of three distinct medication lists. You must act as the arbiter, determining the final, correct path for each medication.

  1. List #1: The Best Possible Medication History (BPMH) from Admission. This is your baseline—the source of truth for what the patient was taking before their hospital stay.
  2. List #2: The Active Inpatient Medication List (MAR). This shows what the patient is currently receiving. It includes continued home meds, new inpatient-only meds (like IV antibiotics), and home meds that were held.
  3. List #3: The Provider’s Proposed Discharge Orders. This is the initial plan drafted by the physician, which must be scrutinized against the other two lists.

Masterclass on Discrepancy Adjudication: The Five Fates of a Medication

Every single medication from both the home list and the inpatient list must be intentionally assigned one of five fates on the final discharge plan. Your job is to ensure no medication is left in limbo.

The Fate The Critical Question Common Error & Pharmacist Intervention
CONTINUE Was this home medication continued throughout the stay and is it intended to be continued after discharge? Error: A dose change made in the hospital (e.g., increased metoprolol) is not reflected in the discharge sig.
Intervention: “Dr. Smith, I see the discharge sig for metoprolol is 25mg BID, but we titrated the patient up to 50mg BID in the hospital for rate control. Should the discharge prescription be for the new 50mg dose?”
RESUME Was this home medication held during the hospital stay for a reason that is now resolved? Error: An ACE inhibitor was held for AKI. The AKI has resolved, but the provider forgets to resume it on the discharge list. This is a very common error.
Intervention: “I noticed the patient’s home lisinopril is not on the discharge list. Their renal function has now returned to baseline. Was the intent to resume it?”
DISCONTINUE Was this home medication intentionally stopped and meant to be permanently discontinued? Error: The provider stops a home medication but doesn’t explicitly communicate this to the patient, who resumes it at home, causing a duplication.
Intervention: During counseling, you must be explicit: “It is very important that you no longer take your old water pill, hydrochlorothiazide. The doctor has replaced it with this new one, torsemide.”
NEW START Was this new medication started in the hospital intended to be continued after discharge? Error: A new medication is started without a clear duration, leaving the patient and PCP confused.
Intervention: “The patient was started on apixaban for a new DVT. The discharge prescription should specify the intended duration (e.g., ‘for 3 months’).”
STOP (Inpatient Only) Was this new medication only for the inpatient stay? Error: A patient is accidentally discharged on an inpatient-only medication like IV antibiotics or a stress ulcer prophylaxis PPI.
Intervention: Scrutinize all inpatient meds. “I see the pantoprazole on the discharge list. That was for SUP while the patient was on high-dose steroids and is no longer indicated. I recommend we remove it.”

3.2 The Art of Simplification: Deprescribing and Regimen Optimization

Your opportunity to improve long-term adherence and safety.

The discharge is more than just a reconciliation; it is a unique “time-out” and a golden opportunity to rationalize and simplify a patient’s entire medication regimen. A hospital stay often adds new medications, leading to an ever-increasing pill burden, a phenomenon known as “polypharmacy.” As the pharmacist, you are the primary advocate for medication minimalism. Every medication on the final discharge list should have fought for its place. Your role is to act as a “deprescribing” champion, identifying and recommending the discontinuation of any medication that is no longer providing a benefit that outweighs its risk or burden.

Retail Pharmacist Analogy: The Annual “Brown Bag” Review

Many community pharmacies hold “brown bag” events where patients bring in all of their medications, including OTCs and old prescriptions. You sit down with them and perform a comprehensive review. The most valuable service you often provide is deprescribing. You identify the bottle of narcotics from a surgery two years ago and recommend they dispose of it. You find three different half-empty bottles of different NSAIDs and recommend they stick to one to avoid GI bleed risk. You find they are still taking a medication for a condition that has resolved. You are not just checking for interactions; you are actively “cleaning house,” simplifying their regimen to what is safe and necessary today.

The discharge reconciliation is the ultimate brown bag review. The hospital admission provides a clear justification to re-evaluate every single home medication and question its continued necessity. You are the expert who can confidently recommend stopping a drug that no longer has a clear indication.

3.2.1 A Masterclass on Deprescribing Targets

During your discharge reconciliation, you should have a high index of suspicion for medications that are prime candidates for discontinuation. This is a proactive, not a passive, review.

  • The Inpatient “Leftovers”: These are the easiest targets.
    • Stress Ulcer Prophylaxis (SUP): Was a PPI or H2RA started in the ICU? Does the patient have a valid outpatient indication for it (e.g., chronic NSAID use, history of GI bleed)? If not, it should be stopped. Continuing it needlessly increases the risk of C. difficile and pneumonia.
    • Sleep Aids: Was zolpidem or trazodone started for hospital-related insomnia? In most cases, these should be discontinued at discharge to avoid long-term use and side effects like falls.
  • The Prescribing Cascade: This is a subtle but critical concept. A prescribing cascade occurs when a new drug is started to treat the side effect of another drug. Your job is to identify the original offender.
    Classic Example: An elderly patient is on amlodipine. They develop peripheral edema. The provider, mistaking it for fluid overload, starts furosemide. The furosemide causes urinary incontinence. The provider then starts oxybutynin for the incontinence. The oxybutynin causes confusion. You have now treated one problem with three extra, unnecessary drugs.
    Your Intervention: “Dr. Smith, I noticed we’re about to discharge Mrs. Davis on furosemide and oxybutynin, which are new for her. Looking back, it seems her leg swelling started right after her amlodipine dose was increased. It’s possible this is all a side effect cascade from the amlodipine. Before we add two new drugs, could we consider switching her from amlodipine to a different antihypertensive, like an ARB, to see if the edema resolves on its own?”
  • Potentially Inappropriate Medications (PIMs) in the Elderly: For any patient over 65, you should mentally screen their entire medication list against the American Geriatrics Society Beers Criteria.
    Common Targets: Long-acting benzodiazepines, anticholinergics (like diphenhydramine), sliding scale insulin (as monotherapy), and chronic NSAID use.
    Your Intervention: “I noticed Mr. White’s home medication list includes daily diazepam for anxiety. As you know, this is on the Beers list due to its long half-life and high risk of falls and confusion in the elderly. Since he is stable now, this might be a good opportunity to discuss a slow taper or a switch to a safer alternative like an SSRI with his PCP.”

3.2.2 Regimen Optimization: Making it Livable

Beyond stopping drugs, you can add immense value by making the final regimen as simple and easy to follow as possible. This is where your community pharmacy expertise in adherence shines.

  • Reduce Frequency: Is the patient on immediate-release metoprolol 25mg BID? This is a great opportunity to recommend a switch to a therapeutically equivalent dose of once-daily metoprolol succinate to reduce pill burden.
  • Use Combination Products: Is the patient on amlodipine and losartan separately? Recommend switching to a single combination tablet to reduce the number of pills they have to manage.
  • Align Administration Times: Look at the whole regimen. Can all the morning pills be safely taken at the same time? Aligning the schedule makes it easier for the patient to build a routine.

3.3 Bridging the Gap: Ensuring Access and a Safe Handoff

Your role as the logistics expert to prevent post-discharge chaos.

A perfect, reconciled, and simplified medication list is useless if the patient cannot obtain and afford the medications when they get home. The final piece of the discharge puzzle is ensuring a seamless logistical transition from the inpatient pharmacy to the outpatient world. This is your home turf. Your deep knowledge of outpatient pharmacy operations, insurance formularies, and prior authorizations is a superpower in the hospital setting, and it is never more valuable than at the moment of discharge.

3.3.1 A Masterclass on Proactive Access Management

You must anticipate and solve access problems *before* the patient is walking out the door.

The Prior Authorization (PA) Intervention

The Scenario: A physician is about to discharge a patient on a new prescription for Entresto for their heart failure. You know from your retail experience that this high-cost, brand-name drug almost always requires a prior authorization.

The Ineffective (Reactive) Workflow: The patient is discharged. They go to their community pharmacy. The pharmacy runs the prescription and gets a “PA Required” rejection. The pharmacy faxes the doctor’s office. It’s a Friday afternoon. The PA doesn’t get approved until Tuesday. The patient goes 4 days without their life-saving heart failure medication, increasing their risk of readmission.

The Pharmacist-Led (Proactive) Workflow:

  1. Anticipate: As soon as you see the proposed order for Entresto, you flag it as a likely PA.
  2. Investigate: You check the patient’s insurance information in the EHR. You may even be able to look up their formulary online.
  3. Initiate: You contact the discharging physician *before they have even written the script*. “Dr. Davis, I see the plan is to send Mr. Johnson home on Entresto. That’s an excellent choice, but his insurance will definitely require a PA. The hospital’s case management team can help us start that paperwork now, before he leaves. Can I send them the request? This will prevent a gap in therapy for the patient.”
  4. Solve: By starting the process while the patient is still in-house, you can often get the PA approved before discharge, ensuring the patient can pick up their medication without any delay.

3.3.2 The “Meds-to-Beds” Program: The Gold Standard Handoff

Many hospitals have implemented “meds-to-beds” or “concierge” pharmacy services. This is a program where the hospital’s own outpatient pharmacy fills the patient’s discharge prescriptions and a pharmacist or technician delivers them directly to the patient’s bedside before they leave. This is widely considered a best practice for improving adherence and preventing readmissions.

Your Role as an Advocate and Coordinator:

  • Identify Candidates: You should be the primary champion for this service. Identify high-risk patients who would benefit most: those on many new medications, those on complex or high-cost drugs, or those with social or transportation barriers.
  • Coordinate the Process: You will often be the liaison between the inpatient medical team and the outpatient pharmacy. You will ensure the final, reconciled prescription list is sent to the outpatient pharmacy in a timely manner, confirm the prescriptions are filled, and coordinate the delivery and counseling at the bedside.
  • The Ultimate Counseling Opportunity: When the medications are delivered, you have the physical bottles in your hand. This is the perfect moment to perform your “Teach-Back” counseling, using the actual vials the patient will be taking home. This tangible, hands-on counseling is far more effective than simply talking about a printed list.