Table 1.

TOC Interventions During and After Hospital Discharge

Intervention	Task
During hospital discharge
Medication reconciliation	Performed by pharmacist and/or pharmacy technicians
Medication education	Use medication lists, which may be created by the pharmacist or generated by using programs such as My Med Action Plan and My Meds Provide the smallest oral syringe size and demonstrate accurate administration technique Use pictograms, particularly for low-literacy patients Apply the teach-back method
Medication access	Provide bedside medication delivery Facilitate medication transfers to the patient’s local pharmacy Arrange mail orders to be completed by the hospital’s outpatient pharmacy Ensure prior authorization of relevant medications to avoid delays
Medication adherence tools	Provide low-cost, low-tech pill boxes Provide handmade medication calendars Send text message medication reminders Recommend smart phone applications Recommend electronic pill boxes with refill reminders Integrate medication adherence equipment into EMRs
After hospital discharge
Comprehensive, patient-specific interventions	Use telephone follow-up, messages via email and/or SMS, or home visits for discharge follow-up Address issues related to medication use and management through patient education, medication order clarification, adjustment of medication therapy, laboratory monitoring, and assistance in obtaining medication
Focused, disease-state or outcomes-specific interventions	Develop a collaborative practice agreement that focuses on specific disease state or patient outcomes such as the pharmacist-driven interventions on susceptibility-antibiotic mismatch, no antibiotics prescribed with positive culture, need for renal dose adjustment, and drug-drug interactions

EMRs, electronic medical records; SMS, short message service; TOC, transitions of care