Improving Medication Management During SNF-to-Home Transitions

Background: This case report focuses on an evolving approach to integrate pharmacists into the skilled nursing facility (SNF) discharge process to ensure appropriate medication use and improve post-discharge outcomes. This report describes the perspectives of 2 residents who were successfully enrolled in a larger pilot pharmacist-led service aimed at improving the discharge process from two University of Pittsburgh Medical Center's-affiliated SNFs to home using Rx Partners, LTC's At-Home medication management services. This was conducted over a 3-month period at two SNFs. Discussion & Conclusion: Thirty-nine residents were introduced to the service, 20 of whom were women, and 27 of whom were White, with a mean age of 74.1 years and an average SNF length of stay of 36 days. Two residents (5%) were ultimately enrolled. The primary outcome studied was resident-reported satisfaction with medication management 30 days after discharge. Secondary outcomes included completion of pharmacist-led education on high-risk medications, enrollment and continuation of pharmacy services, and medication-related rehospitalization or emergency department use within 30 days. Both residents enrolled reported excellent ratings across all domains of care on the satisfaction survey at the 30-day follow-up. One of the 2 residents had a 30-day rehospitalization not related to medication use. Despite design limitations, this pilot study reinforces the potential advantages of a medication discharge service before broader implementation to address a critical gap in care for older adults from a long-term care facility.