By Annette M. Boyle

BOSTON — For many older veterans, the transition from hospital to home can create confusion about which medications to take when. For veterans with cognitive impairment, the challenge increases — and so does the risk of readmission arising from adverse drug events and nonadherence.

The crux of the problem lies with incomplete, inaccurate or misunderstood discharge instructions, which are associated with half of all hospital-related medication errors and 20% of all adverse drug events, according to the American Society of Health-System Pharmacists.

By implementing a quality-improvement program that featured a follow-up phone call from a pharmacist to discharged patients who were older than 64, at risk for delirium or on a dementia medication, the VA Boston Healthcare System was able to significantly reduce readmissions in this vulnerable population. Results of the initiative based on a retrospective secondary data analysis were published in the Journal of the American Geriatrics Society.1

“By combining cognitive impairment and transitions of care, we knew there was an ultra-high risk group at an ultra-high risk time,” said co-author James L. Rudolph, MD, formerly the site director for the Geriatric Research, Education and Clinical Center at the VA Boston Healthcare System and now director of the Center of Innovation in Geriatric Services at the Providence VA Medical Center.

The Boston team identified high-risk patients based on age and orders for acetylcholinesterase inhibitors such as donepezil, galantamine or rivastigmine or N-methyl-D-aspartate antagonists or notations of cognitive impairment, sensory impairment or dehydration.

Managing multiple medications can be a cognitively demanding task for any patient, but those with dementia have more than twice the risk of other patients of taking the wrong dosage. As a result, they have greater risk of adverse drug effects, repeat hospitalization or admission to a long-term care facility, noted the authors.

The Boston team quantified how fraught the hospital-to-home transition can be. “We sent 60% of ultra-high-risk patients home from the hospital with medication discrepancies between the instructions and the medication orders. Once home, these patients had to reconcile the medications in the bottles, the discharge medication instructions and what they used to do,” Rudolph told U.S. Medicine.


*Frequency represents the percentage of patients with the discrepancy. Totals add to more than 100% because some patients had multiple discrepancies.

And, veterans were not simply taking one or two medications: the average patient had nearly 15 discharge medications. In addition, patients had an average of almost three medication changes and 1.4 discrepancies between medication order and instructions.

The Pharmacological Intervention in Late Life (PILL) Service at the Boston VAMC developed a program to improve patient safety and reduce adverse events. The intervention included comprehensive medication reconciliation and geriatric medication review, combined with a pharmacist’s call to discharged patients.

During a three-month pilot, pharmacists attempted to reconcile the medications while the patients were still in the hospital and to place the follow-up call the day of discharge. They found, however, that the discharge medications often were not known and that the veterans were focused more on returning home than what drugs they would take once they got there. Immediately after going home, they were more concerned about settling back in than reviewing their medications. So, the researchers found that follow-up two to three days after discharge worked better and was the standard adopted for the program following the pilot.

The study population included 501 veterans with a mean age of 79.5 years, 98% of whom were male. Four out of five patients had a high risk of delirium, and 19% were on dementia medications. Sixty-one percent had discrepancies between their medication orders and discharge instructions, and those with discrepancies had an average of 2.3.

Pharmacists failed to reach 132 individuals. They reached another 112, but had conversations of less than five minutes, indicating a lack of engagement on the patient’s part. The remainder (257) were reached and engaged. Of those not reached, 37.1% were readmitted within 60 days of discharge, compared with 34% of those reached but not engaged and 25% of those reached and engaged by the pharmacist.

Readmission also was associated with length of pharmacist’s call. Each additional five minutes of call time correlated with 15% lower likelihood of 60-day readmission.

“We believe the reduction in readmission was related to intervening with a pharmacist at this crucial time,” Rudolph noted. While the average call was 10 minutes, “readmission drops for additional time spent on the phone. We viewed this as an engagement process. The more willing the veteran was to engage, the less likely they were to need readmission.”

The calls and veteran engagement paid off. The program cost $613 per patient. The average readmission cost, however, was $11,600, so the lower rate of readmissions in the intervention group saved between $138,134 and $206,696 over the two years studied.

The study has significant implications for other clinicians in the VA, Rudolph said. “First, it is very important to understand the cognitive status of the veterans we serve. Taking medication is a cognitively demanding task. Try to take one, let alone 15.” As medication is the most common medical intervention, considering how an individual veteran will cope with additional medications and his or her ability to take them safely must be factored into the prescribing process.

“Second, we are creating an unsafe situation with our current discharge processes,” he suggested. The Boston VAMC is not unique in having a high percentage of discrepancies; previous studies in other healthcare systems have found that 71% of cases had at least one medication reconciliation problem, noted the authors.

“Third, as important as prescribing is, [so is] understanding what a current patient is taking. Our list is different than the orders and different than what the patient does on a daily basis,” he said. That can lead to confusion for the patients, duplicative medications and miscommunication with primary care physicians.

Rudolph encouraged clinicians to have an open dialogue with their patients about their medications — one that acknowledges the challenges of taking a dozen or more medications and solicits questions and comments about their side effects and effectiveness.

The YouTube video “Providers, Patients and Pills: A Prescription for Partnership” developed by the Boston team can help pharmacists and providers gain a clearer picture of how and whether patients are taking prescription medications, what non-prescription medications and supplements they are using, and whether they are having difficulty keeping track of their medications.

1 Paquin AM, Salow M, Rudolph JL. Pharmacist calls to older adults with cognitive difficulties after discharge in a Tertiary Veterans Administration Medical Center: a quality improvement program. J Am Geriatr Soc. 2015 Mar;63(3):571-7.