CHPPC Module 41, Section 12: Discharge Continuity
MODULE 41: MEDICATION ORDER SAFETY: THE PHARMACIST’S PRIMARY SHIELD

Section 12: Discharge Continuity

Translating inpatient regimens into clear, feasible, and safe outpatient prescriptions.

SECTION 41.12

Discharge Continuity

The Pharmacist as the Final Guardian of a Safe Transition Home.

41.12.1 The “Why”: The Most Dangerous Journey in Healthcare

The physical journey for a patient leaving the hospital may only be a few miles, but the journey their medication regimen takes is one of the most perilous in all of healthcare. A patient’s medication list upon discharge is often a complex, sometimes contradictory, patchwork quilt of home medications, new inpatient treatments, and temporary therapies. For a patient who is already physically weakened and cognitively overwhelmed from their hospital stay, being handed a stack of papers with a dozen prescriptions and a vague instruction to “follow up with your primary care doctor” is a recipe for disaster. It is a well-documented fact that medication discrepancies—errors of omission, commission, and conflicting instructions—are rampant during this transition, leading to adverse drug events, therapeutic failure, and staggering rates of hospital readmission within 30 days.

Think of the entire hospital stay as a race. The clinical team—doctors, nurses, specialists, and you, the pharmacist—have worked tirelessly to stabilize the patient, treat their acute illness, and get them to the finish line, which is a safe discharge. The discharge process is the final, critical lap of that race. If we fumble the handoff at this last stage, everything that came before it can be undone. A patient stabilized from a heart failure exacerbation who is discharged without a clear, affordable prescription for their diuretic will be back in the emergency department with fluid overload within a week. A patient bridged from a heparin drip to warfarin who leaves without understanding the need for INR follow-up is at extreme risk of a clot or a major bleed.

Your role as the hospital pharmacist in this process has evolved from a final check to a central, indispensable function. You are no longer just verifying the legality of the discharge prescriptions. You are the medication continuity architect. You are the one professional who is uniquely positioned to look at the entire picture: the medications the patient came in on, the complex changes that happened during their stay, and the practical realities of what their life will look like once they get home. Your job is to perform a final, definitive medication reconciliation, translate the complex inpatient regimen into a simple, actionable outpatient plan, and ensure the patient and their next caregivers understand that plan completely. This is arguably one of the most impactful activities a hospital pharmacist performs, directly preventing patient harm and saving the healthcare system millions by preventing unnecessary readmissions.

Retail Pharmacist Analogy: Consolidating the Vacation Medications

Imagine a longtime patient, an elderly woman with multiple chronic conditions, comes into your pharmacy after returning from a two-week trip to visit her daughter out of state. She looks exhausted and confused. She dumps a large plastic bag on your counter. Inside is a chaotic collection of pill bottles.

There are her regular bottles from your pharmacy. There’s a bottle of an antibiotic she got from an urgent care clinic for a UTI while she was away. There’s a bottle of oxycodone with only a few tablets left that her son-in-law, a dentist, gave her for a toothache. There’s a blister pack of a new blood pressure pill her daughter’s doctor gave her as a sample because her pressure was high one morning. And there’s a handwritten note that says “Stop the water pill if you feel dizzy.” She looks at you and says, “I have no idea what I’m supposed to be taking anymore.”

What do you do? You don’t just refill her regular medications. You take ownership of the problem. You sit down with her and perform a comprehensive medication reconciliation, but in reverse. This is a discharge reconciliation.

  • Step 1 (Continue): You confirm she should finish the full course of the urgent care antibiotic.
  • Step 2 (Discontinue): You tell her to stop taking the leftover oxycodone now that her toothache is resolved and instruct her on how to dispose of it safely. You also see that she is taking both her regular lisinopril and the new sample of amlodipine. You recognize this therapeutic duplication and, after a quick call to her primary care physician, you instruct her to stop the sample and continue with her regular regimen.
  • Step 3 (Modify/Clarify): You address the confusing note about the “water pill.” You explain that she should only hold her furosemide if her blood pressure is below a certain number or if she has specific symptoms, and you encourage her to buy a home blood pressure cuff.

At the end of this 15-minute intervention, you have created a single, consolidated, and accurate medication list. You have prevented multiple potential adverse events. This act of untangling a complex, temporary medication history and creating a clear, forward-looking plan is the exact intellectual process of a hospital discharge reconciliation. You are taking the “inpatient MAR” (the chaotic bag of pills) and comparing it to the “home med list” to create a safe and effective “discharge medication list.” You already have the core skills of a medication detective; you will now apply them at one of the most critical moments in a patient’s care journey.

41.12.2 The Three Pillars of a Pharmacist-Led Discharge

A safe and effective discharge from a pharmacy perspective is not a single event, but a process built on three core pillars. As a hospital pharmacist, you are responsible for ensuring each of these pillars is strong for every patient you care for. A failure in any one of these areas can compromise the entire transition and lead to patient harm.

Pillar 1:
Reconciliation

The cognitive act of comparing the patient’s inpatient medication list to their pre-admission list and deciding the final disposition of every single drug: Continue, Discontinue, or Modify. This is the clinical foundation.

Pillar 2:
Education & Counseling

The human act of translating the complex, reconciled list into simple, actionable instructions for the patient and their family, ensuring they understand what to take, why they are taking it, and what to watch out for. This is the educational bridge.

Pillar 3:
Facilitation & Access

The practical act of ensuring the patient can actually obtain their medications. This includes addressing affordability issues, confirming prescriptions are sent to the correct pharmacy, and often running a “Meds to Beds” program. This is the logistical link.

41.12.3 Masterclass in Discharge Reconciliation: The Disposition Decision

This is the intellectual heart of the discharge process. It requires you to look at every single medication on the patient’s active inpatient profile and make a deliberate, conscious decision about its fate. You are cleaning up the medication list for the outside world. To do this effectively, you must understand why the patient was taking the drug in the first place and whether that reason still exists upon discharge.

The following table simulates the thought process for a complex patient being discharged after a 5-day stay for a COPD exacerbation complicated by community-acquired pneumonia. You must go line by line through their inpatient MAR and decide the disposition of each medication.

Case Study: 68 y/o Male with COPD/CAP Discharge

Inpatient Medication Order Reason for Use Inpatient Pharmacist’s Disposition Decision Required Action & Outpatient Prescription Details Key Counseling Point for Patient
Albuterol 2.5 mg Nebulizer q4h PRN Bronchodilator for COPD/wheezing CONTINUE (Modify Route) Patient uses a metered-dose inhaler (MDI) at home. Discontinue the nebulizer order. Prescribe Albuterol HFA Inhaler, 2 puffs every 4-6 hours as needed for shortness of breath. “We were giving you breathing treatments through a machine here. At home, you will go back to using your regular blue rescue inhaler as needed.”
Ipratropium Nebulizer q6h Bronchodilator for COPD CONTINUE (As part of Combo) Patient uses a combination LAMA/LABA inhaler at home (e.g., Anoro). Do not write a separate ipratropium script. Ensure their home combo inhaler is prescribed. Anoro Ellipta 1 puff daily. “The scheduled breathing treatments will stop. You’ll go back to using your once-a-day Anoro inhaler for maintenance.”
Methylprednisolone 40 mg IV daily Systemic steroid for COPD exacerbation DISCONTINUE (Complete Course) The standard course for a COPD exacerbation is 5 days. The patient has completed this course. No steroid prescription is needed at discharge. “The strong IV steroid we gave you for the inflammation in your lungs is finished. You do not need to take any steroid pills at home.”
Ceftriaxone 1g IV daily Antibiotic for CAP MODIFY (IV to PO Step-down) Patient has completed 3 days of IV therapy and is clinically improving. Step down to an oral antibiotic to complete a total 7-day course. Prescribe Doxycycline 100 mg PO BID for 4 more days. “We are stopping the IV antibiotic. You must take this new antibiotic pill, doxycycline, twice a day for the next 4 days to fully treat the pneumonia.”
Apixaban 5 mg PO BID Home med for Atrial Fibrillation CONTINUE This is a chronic, life-saving medication. Ensure a new prescription is written for a 30- or 90-day supply. Apixaban 5 mg PO BID. Check for affordability issues. “It is very important that you continue taking your Eliquis blood thinner twice a day, every day, to prevent a stroke.”
Enoxaparin 40 mg SUBQ daily VTE Prophylaxis DISCONTINUE This was given to prevent blood clots while the patient was immobile in the hospital. Since he is now walking and on a full-dose anticoagulant (apixaban), this is no longer needed and would be a dangerous therapeutic duplication. “We are stopping the little shot in your belly. Your Eliquis pill will protect you from blood clots now.”
Pantoprazole 40 mg IV daily Stress Ulcer Prophylaxis DISCONTINUE Patient was on an IV steroid and critically ill, justifying SUP. He does not have a history of GERD or an ulcer and does not meet indications for chronic PPI use as an outpatient. This is a classic de-prescribing opportunity. “The medication we gave you to protect your stomach from the stress of being sick is no longer needed and can be stopped.”
Ondansetron 4 mg IV q6h PRN nausea Nausea treatment MODIFY (As Needed Basis) Patient may experience nausea at home. Providing a small quantity of an oral antiemetic is reasonable. Prescribe Ondansetron 4 mg ODT, 1 tablet every 8 hours as needed for nausea, #12 tablets. “We are giving you a prescription for a few of the dissolvable nausea pills in case you feel sick to your stomach when you get home.”

41.12.4 Pillar 2 Deep Dive: High-Impact Discharge Counseling

Hospital discharge counseling is fundamentally different from a new prescription counseling session in a retail pharmacy. You are not focused on a single new drug; you are focused on managing change. The patient is often anxious, tired, and overwhelmed. Your counseling cannot be a monotonous recitation of every side effect. It must be a targeted, prioritized conversation that focuses on the most critical, actionable information. The goal is not just to inform, but to ensure comprehension.

The “Focus on the Three” Counseling Method

An effective discharge counseling session should be structured around answering the three most important questions for the patient. Use this as your script and mental model.

  1. Question 1: “What am I STARTING that is new?”

    Focus on the truly new medications. In our case study, this is the doxycycline. Physically show the patient the bottle. Explain in simple terms what it’s for (“This is to finish treating the pneumonia.”) and exactly how to take it (“Twice a day for the next 4 days. It’s very important you finish all of them.”).

  2. Question 2: “What am I STOPPING?”

    This is just as important as what’s new, as it prevents errors of commission. Be explicit. “We are stopping the shots in your belly to prevent blood clots. We are also stopping the stomach medicine, pantoprazole. You should not take these anymore, even if you have some left over from a previous time.”

  3. Question 3: “What has CHANGED?”

    This covers modifications to home medications. “The biggest change is your breathing medicines. We are stopping the machine treatments. You will go back to using your blue rescue inhaler as needed, and your daily Anoro inhaler. Can you show me how you use your Anoro inhaler?”

The Most Important Question You Can Ask: “Teach-Back”

After you have explained the changes, you must close the loop to ensure the patient actually understood. Assuming comprehension is a common and dangerous mistake. The “teach-back” method is the single best tool to assess understanding. It is a respectful way of asking the patient to explain the plan in their own words.

Do NOT ask: “Do you have any questions?” (The answer will almost always be “no.”)

DO ask:
“I know this is a lot of information. Just to make sure I did a good job explaining everything, can you tell me in your own words…

  • …which new medicine you need to take for the next 4 days?”
  • …which medicines you will be stopping completely?”
  • …how you will be taking your breathing treatments now that you are home?”

The patient’s response will immediately tell you if your counseling was effective or if you need to review a key concept again. This simple technique is one of the most powerful tools in preventing post-discharge medication errors.

41.12.5 Pillar 3 Deep Dive: Facilitation, Access, and the “Meds to Beds” Program

You can perform a perfect reconciliation and provide award-winning counseling, but if the patient cannot obtain their medications after discharge, all of that work is for nothing. The final pillar of a safe discharge is ensuring access. This involves anticipating and solving the practical and financial barriers that prevent patients from filling their prescriptions. In recent years, one of the most effective strategies for overcoming these barriers is the implementation of a “Meds to Beds” (or “Meds to Go”) program.

A “Meds to Beds” program is an outpatient or discharge pharmacy service, typically run by the hospital’s own pharmacy department, that proactively fills the patient’s discharge prescriptions and delivers them directly to the patient’s bedside before they leave the hospital. The pharmacist or technician completes the adjudication, collects any copays, and provides the counseling right there in the room, with the actual prescription vials in hand. This seemingly simple logistical change has a revolutionary impact on medication adherence and post-discharge outcomes.

The “Meds to Beds” Advantage: Overcoming the Barriers to Adherence

Common Barrier to Filling Prescriptions How “Meds to Beds” Solves It
Transportation Issues: Patient is weak, has no family available, or has no car to get to an outside pharmacy. The pharmacy comes to the patient. This barrier is completely eliminated.
Sticker Shock / Affordability: Patient arrives at their community pharmacy only to find a new, expensive medication has a $150 copay they cannot afford. They abandon the prescription. The Meds to Beds pharmacist discovers the high copay while the patient is still in the hospital. This gives the pharmacist time to intervene: find a manufacturer coupon, work with the prescriber to switch to a cheaper, therapeutically equivalent alternative, or connect the patient with social work for financial assistance. The problem is solved before it leads to non-adherence.
Pharmacy/Formulary Issues: The prescription is accidentally sent to the wrong pharmacy, or the patient’s local pharmacy doesn’t have the medication in stock. The hospital pharmacy has the patient’s information and can proactively manage the stock and delivery. The chance of the prescription getting “lost” is near zero.
Confusion / Health Literacy: The patient leaves with a paper prescription, gets home, and cannot remember what it was for or why it was important. They never fill it. The counseling is done with the physical bottles in hand. The pharmacist can open the bottle, show the patient the pill, and apply a sticker or marking. This hands-on, multi-sensory education is far more effective and memorable than abstract counseling about a piece of paper.
The Pharmacist’s “Meds to Beds” Workflow
  1. Identify the Patient: As soon as a patient is marked as “likely to be discharged in the next 24 hours,” the discharge pharmacy team is alerted. A technician or pharmacist approaches the patient to see if they would like to participate.
  2. Gather Information: The technician obtains the patient’s prescription insurance information and their preferred outpatient pharmacy for future refills.
  3. Proactive Adjudication: As soon as the physician writes the discharge prescriptions in the EHR, the pharmacy team transmits them to the insurance. This is done hours before the patient actually leaves.
  4. Problem Solving: This is the key step. If any rejections occur (prior authorization needed, high copay, not covered), the pharmacist has a window of several hours to solve the problem while the patient is still a captive audience.
  5. Fill & Delivery: Once all issues are resolved, the prescriptions are filled and labeled.
  6. Bedside Counseling & Payment: A pharmacist takes the bag of medications to the patient’s room. They perform the final counseling session using the actual vials. They collect the copay via a mobile payment system. The patient is now ready to walk out the door with everything they need, fully educated and empowered.