Clinical outcomes of a home-based medication reconciliation program after discharge from a skilled nursing facility

Pharmacotherapy. 2008 Apr;28(4):444-52. doi: 10.1592/phco.28.4.444.


Study objective: To assess the impact of a pilot pharmacist-managed medication reconciliation program on mortality and use of health care services in patients discharged to home from a skilled nursing facility (SNF).

Design: Quasi-experimental, controlled trial.

Setting: Health maintenance organization (HMO).

Patients: Five hundred twenty-one HMO members.

Intervention: Patients were assigned to the medication reconciliation program (113 patients) or to the usual care control group (408 patients) after discharge to home from an SNF. Assignment to the medication reconciliation group or to the control group was based on provider submission of a discharge summary within 0-48 hours of discharge or more than 48 hours after discharge, respectively.

Measurements and main results: Integrated electronic medical and pharmacy data and multivariate analyses were used to assess the medication reconciliation program with regard to its impact on postdischarge mortality, rehospitalization, and ambulatory clinic and emergency department visits. Compared with usual care during the 60 days after discharge from the SNF, patients who received the medication reconciliation intervention had an adjusted 78% reduction in the risk of death (adjusted hazard ratio 0.22, 95% confidence interval [CI] 0.06-0.88) and a trend toward an increased rate of ambulatory care visits (adjusted incidence risk ratio 1.17, 95% CI 0.99-1.37). No significant differences were noted in adjusted risks of an emergency department visit and rehospitalization (p>0.05) between the medication reconciliation and usual care groups.

Conclusion: Our data support the hypothesis that a formal medication reconciliation process, with its increased coordination of information between health care providers and patients, can decrease mortality after discharge from an SNF. Our findings support the role of medication reconciliation as an integral step in the transitional care process and interests of health care accrediting agencies, such as the Joint Commission, that have included medication reconciliation as an important initiative.

Publication types

  • Controlled Clinical Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Colorado
  • Continuity of Patient Care / organization & administration*
  • Female
  • Health Maintenance Organizations
  • Home Care Services / organization & administration*
  • Humans
  • Male
  • Medical History Taking / methods*
  • Medication Errors / prevention & control
  • Mortality
  • Multivariate Analysis
  • Patient Discharge
  • Pharmaceutical Preparations / administration & dosage
  • Pharmaceutical Services / organization & administration
  • Pharmacists / organization & administration*
  • Pilot Projects
  • Skilled Nursing Facilities
  • Survival Analysis


  • Pharmaceutical Preparations