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MODULE 15: TRANSITIONS OF CARE & DISCHARGE MED REC
Section 5: Community Handoff Best Practices
In this final, critical section, we close the last gap in the transition of care. The discharge process does not end when the patient leaves the hospital; it ends when the next providers in the chain of care—the primary care physician and the community pharmacist—have received a clear and complete handoff of the therapeutic plan. Your role as the hospital pharmacist is to be the architect of this handoff. You will learn the best practices for communicating critical medication changes, the rationale for those changes, and the required follow-up, ensuring the baton of patient care is passed flawlessly, not dropped. This is where you leverage your unique understanding of both the inpatient and outpatient worlds to ensure true continuity of care.
5.1 Why the Handoff Matters: Preventing Information Decay
Understanding your role in preserving the integrity of the care plan after discharge.
“Information decay” is a well-documented phenomenon in healthcare. With each handoff from one provider to another, critical details and the “why” behind clinical decisions are lost. The discharge summary, often a dense and lengthy document, is a prime example. A physician may read the summary and see that a home medication was stopped, but not understand the reason. A community pharmacist may receive a new prescription but have no context as to why it was started or what monitoring is required. This information decay leads to confusion, potential medication errors, and a fragmented approach to the patient’s long-term care.
The pharmacist-led handoff is the antidote to information decay. By creating a specific, concise, and medication-focused communication for the outpatient providers, you preserve the therapeutic intent established in the hospital. You are not just transmitting a list; you are transmitting a plan, complete with rationale and required follow-up. This ensures that the thoughtful therapeutic decisions made during the hospitalization are not lost the moment the patient leaves the building.
Retail Pharmacist Analogy: Receiving a Garbled Voicemail vs. a Clear E-Script
You have experienced both ends of this spectrum every day of your career. On one hand, you get a garbled, rushed voicemail from a medical assistant: “Hi, this is Dr. Smith’s office. Can you refill Mrs. Jones’s lisinopril?” This is a low-quality handoff. You have no context. Is it the same dose? Did the doctor see her? Is there a reason for the call?
On the other hand, you receive a clear, detailed electronic prescription. It has the patient’s name, DOB, the exact drug, dose, frequency, quantity, refills, and even a note in the comments section: “Patient’s BP was 150/90 in office today. Please counsel on adherence.” This is a high-quality handoff. It gives you all the information and context you need to care for the patient safely and effectively.
Your goal in the discharge handoff is to be the creator of the “clear e-script,” not the “garbled voicemail.” You are packaging the critical information in a way that is immediately useful and actionable for the next provider.
5.2 The Primary Care Physician (PCP) Handoff: A Masterclass on the Pharmacist’s Addendum
Crafting a concise, high-impact medication action plan for the discharge summary.
The official hospital discharge summary is the primary legal document that communicates the events of the hospitalization to the PCP. However, it is often written by a junior resident, can be dozens of pages long, and may lack the specific medication-related details the PCP needs to safely resume care. A best practice is for the discharging pharmacist to author a specific “Pharmacist’s Medication Recommendations” or “Medication Action Plan” section to be included within the formal discharge summary. This addendum is your opportunity to speak directly to the PCP, from one provider to another, and highlight the most critical medication-related issues.
5.2.1 The Four Pillars of an Effective Pharmacist Handoff Note
Your note should not be a simple list of the discharge medications. It must provide context and a clear action plan. It should be structured around these four pillars.
- Rationale for Key Changes: This is the most important pillar. You must explain the “why” behind any major medication changes. The PCP was not in the hospital; they do not know the story.
- Required Follow-Up & Monitoring: Clearly state any time-sensitive monitoring that is now the PCP’s responsibility. Be specific about the test and the timing.
- Intended Durations for New Therapies: For any new, short-term medication (especially antibiotics or anticoagulants), you must specify the intended stop date.
- Opportunities for Further Optimization: Suggest potential next steps for the PCP to consider, positioning yourself as a collaborative consultant.
Masterclass on Writing the Pharmacist’s Addendum
Here is a gold-standard template and example. Note how it is structured, concise, and actionable.
Template:
PHARMACIST'S MEDICATION RECOMMENDATIONS & FOLLOW-UP PLAN: This patient was managed by the inpatient pharmacy team during their admission. The following are key recommendations for post-discharge medication management: 1. Anticoagulation Management: - [Drug Name] was initiated for [Indication]. - Required Follow-Up: [e.g., Follow-up INR in 3 days]. - Intended Duration: [e.g., Therapy for a total of 3 months]. 2. Management of Medications Held During Admission: - The following home medication(s) were held: [Drug Name(s)]. - Reason Held: [e.g., Acute Kidney Injury]. - Recommendation: [e.g., The AKI has resolved. We recommend resuming the lisinopril and rechecking SCr/K+ in 1 week]. 3. Rationale for New/Changed Chronic Medications: - [Drug Name] was increased/decreased/switched to [New Drug] for [Reason]. - Recommendation: [e.g., Please continue metoprolol succinate at the new dose of 100mg daily for improved rate control]. 4. Deprescribing/Simplification: - The following unnecessary medication(s) were discontinued: [Drug Name(s)].
Example Case: Patient admitted for DVT, found to have AKI.
PHARMACIST'S MEDICATION RECOMMENDATIONS & FOLLOW-UP PLAN: This patient was managed by the inpatient pharmacy team during their admission. The following are key recommendations for post-discharge medication management: 1. Anticoagulation Management: - Apixaban was initiated for an acute, provoked left lower extremity DVT. - Required Follow-Up: No specific lab monitoring required for apixaban. - Intended Duration: The plan is for a total of 3 months of therapy. 2. Management of Medications Held During Admission: - The following home medications were held: Lisinopril 20mg daily and Ibuprofen 800mg PRN. - Reason Held: Patient was admitted with an AKI (SCr 2.5), which was attributed to dehydration and heavy NSAID use. - Recommendation: The patient's renal function has returned to baseline (SCr 1.1). We recommend resuming the lisinopril 20mg daily. We have counseled the patient to avoid all NSAIDs permanently. Please recheck SCr and K+ within 1-2 weeks of resuming the lisinopril. 3. Rationale for New/Changed Chronic Medications: - No other chronic medications were changed. 4. Deprescribing/Simplification: - The patient was counseled to discontinue the use of OTC ibuprofen. Acetaminophen was recommended as a safer alternative for pain.
5.3 The Community Pharmacist Handoff: Closing the Final Loop
A proactive communication to your outpatient colleague.
This is a step that is often missed but can provide immense value. A direct, pharmacist-to-pharmacist handoff for high-risk patients is a powerful best practice. As a former community pharmacist, you know exactly what information you wished you had when a confused post-discharge patient showed up at your counter. Now you are in the position to provide that information proactively. This communication can be a brief, targeted phone call or a secure electronic message, and it should be reserved for situations with the highest potential for post-discharge confusion or error.
5.3.1 When to Make the Call: High-Risk Triggers
You should consider a direct handoff to the patient’s chosen community pharmacy in these scenarios:
- New High-Alert Medication Start: Especially for anticoagulants (warfarin, DOACs), insulin, or complex pain regimens.
- Complex Tapers or Titrations: If the patient is being discharged with a complex steroid taper or instructions to titrate a new heart failure medication.
- Multiple, Confusing Changes: If a patient with polypharmacy had many medications stopped, started, and changed, a heads-up to their pharmacist can be invaluable.
- Formulary/Access Issues Anticipated: If you had to prescribe a non-formulary alternative or know that a high-cost medication will require a PA, giving the community pharmacy a warning allows them to prepare.
- Patients with Low Health Literacy or Cognitive Impairment: If you are concerned about a patient’s ability to manage their regimen, enlisting the community pharmacist as an extra layer of support and follow-up is a great safety strategy.
A Masterclass on the Pharmacist-to-Pharmacist Handoff Script
This should be a brief, peer-to-peer conversation that gets right to the point.
Case: Patient being discharged on a new warfarin regimen.
- Identify & Introduce: “Hi, my name is Chris, I’m a clinical pharmacist at University Hospital. I’m calling about a mutual patient, Jane Doe, who is being discharged today and should be coming to your pharmacy with some new prescriptions.”
- State the High-Risk Issue: “I wanted to give you a quick heads-up about her regimen. We started her on warfarin for a new diagnosis of atrial fibrillation. Her first dose is tonight.”
- Provide the Actionable Details: “Her starting dose is 5mg once daily. We have given her a paper prescription for the first 30 days. Most importantly, we have scheduled her first follow-up INR check for this Friday, October 7th, at the hospital’s anticoagulation clinic. I’ve counseled her on this, but she is a bit overwhelmed.”
- Make the Collaborative “Ask”: “I would be very grateful if you could reinforce the importance of that first INR check when she comes to pick up the prescription. Also, she has a number of other changes, but the warfarin is the most critical one. I’ve documented the rest in the discharge summary that will be sent to her PCP.”
- Offer to Be a Resource: “If you run into any issues or have any questions, please feel free to call me directly at [your number]. Thanks for your help.”
This 90-second phone call builds a powerful bridge between the inpatient and outpatient worlds. It demonstrates professional respect for your community colleague, provides them with the critical information they need to prevent an error, and enlists them as an active partner in the patient’s care.
