RESEARCH ARTICLE

Pediatric Patient-Centered Transitions FromHospital to Home: Improving the DischargeMedication ProcessLeah A. Mallory, MD,a Noah P. Diminick, MD,a Jonathan P. Bourque, PharmD,b Meredith R. Bryden, MD,a Jessica L. Miller, PharmD,b Nancy M. Nystrom, PhD,b

Melanie R. Lord, RN,c Lorraine L. McElwain, MDa

A B S T R A C T OBJECTIVES: Medications prescribed at hospital discharge can lead to patient harm if there are access barriersor misunderstanding of instructions. Filling prescriptions before discharge can decrease these risks. We aimedto increase the percentage of patients leaving the hospital with new discharge medications in hand to 70% by18 months.

METHODS: We used sequential plan-do-study-act cycles from January 2015 to September 2016. We usedstatistical process control charts to track process measures, new medications filled before discharge, and rates ofbedside delivery with pharmacist teaching to the inpatient pediatric unit. Outcome measures included nationalpatient survey data, collected and displayed quarterly, as well as caregiver understanding, comparing inaccuracyof medication teach-back with and without medications in hand before discharge.

RESULTS: Rates of patients leaving the hospital with medications in hand increased from a baseline of 2% to85% over the study period. Bedside delivery reached 71%. Inaccuracy of caregiver report during a postdischargephone call decreased from 3.3% to 0.7% (P , .05) when medications were in hand before discharge. Patientsatisfaction with education of new medication side effects increased from 50% to 88%.

CONCLUSIONS: By using an engaged interprofessional team, we optimized use of our on-site outpatientpharmacy and increased the percentage of pediatric patients leaving the hospital with new dischargemedications in hand to .80%. This, accompanied by increased rates of bedside medication delivery andpharmacist teaching, was associated with improvements in caregiver discharge-medication related experienceand understanding.

aDepartments ofPediatrics and cNursing,

The Barbara BushChildren’s Hospital atMaine Medical Center,Portland, Maine; and

bDepartment ofPharmacy, Maine MedicalCenter, Portland, Maine

www.hospitalpediatrics.orgDOI:https://doi.org/10.1542/hpeds.2017-0053Copyright © 2017 by the American Academy of Pediatrics

Address correspondence to Leah A. Mallory, MD, Department of Pediatrics, The Barbara Bush Children’s Hospital at Maine MedicalCenter, 22 Bramhall St, Portland, ME 04102. E-mail: mallol@mmc.org

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Dr Mallory participated in the conceptualization and design of the study, designed the data collection instruments, participated inmonthly plan-do-study-act cycles, and drafted the initial manuscript; Drs Diminick and Bryden participated in monthly plan-do-study-actcycles and assisted in the initial manuscript draft; Drs Bourque and Miller participated in monthly plan-do-study-act cycles, assistedwith data collection as unit-based inpatient pharmacists, and reviewed and revised the manuscript; Dr Nystrom participated in monthlyplan-do-study-act cycles, assisted with data collection as the outpatient pharmacy liaison, and reviewed and revised the manuscript;Ms Lord participated in monthly plan-do-study-act cycles and reviewed and revised the manuscript; Dr McElwain participated in theconceptualization and design of the study, conducted data analysis, and assisted in the initial manuscript draft; and all authorsapproved the final manuscript as submitted.

HOSPITAL PEDIATRICS Volume 7, Issue 12, December 2017 723

by guest on November 27, 2020www.aappublications.org/newsDownloaded from

Hospital-to-home transitions presentsafety risks to patients. Several pediatriccollaboratives have formed to studyand improve safety during this criticalhandoff.1–3 Discharge medications are a keycomponent to safe hospital discharge.Challenges with medication access andcaregiver understanding of administrationinstructions can lead to medication errors,hospital readmissions, and pooroutcomes.4–6 To eliminate unanticipatedbarriers to access, recent efforts have beenfocused on filling prescriptions through acontracted pharmacy and delivery beforedischarge. Having medications in hand atdischarge decreased readmission rates forpediatric patients with asthma.7,8 Teachingcaregivers with home medications inhand can improve the understanding ofmedication use, increase awareness of sideeffects, and reduce administration errors.5,9

This is especially important in pediatrics,for which liquid medication formulationspresent an even greater likelihood fordosing errors.5 The teach-back educationtechnique and requesting caregivers torepeat back instructions can improvecaregiver understanding and preventadministration errors.10

In 2014, our hospital became 1 of 4 pilotsites for Project Improving Pediatric Patient-Centered Care Transitions (IMPACT), anAmerican Academy of Pediatrics–affiliatedquality improvement research collaborativeaiming to implement and test a pediatrictransitions bundle.1 In the first year of thisproject, 7% of caregivers reached via apostdischarge phone call were unable toteach-back the medication plan accurately.Additionally, patient experience surveyresponses related to newly prescribedmedications were below nationalbenchmarks. Our Project IMPACTinterprofessional improvement teamidentified discharge medications as anarea of vulnerability and formed asubgroup to focus on this area. Wehypothesized that family-centered,discharge medication–related outcomescould be improved by filling prescriptionsbefore discharge and performingmedication-related discharge teaching withmedications in hand by using the teach-backtechnique. We aimed to increase the

percentage of patients leaving the hospitalwith new discharge medications in hand to70% at 18 months. We anticipated thatleaving the hospital with medications inhand would enable higher quality teaching,improve patient or caregiver experience,and provide better understanding ofmedication side effects and administrationinstructions.

METHODSContext

The Barbara Bush Children’s Hospital is anurban, academic children’s hospital withinthe Maine Medical Center (MMC), a 600-bedhospital located in Portland, Maine. Theinpatient pediatric unit (IPU) has 37 beds,excluding the newborn nursery, NICU, andPICU. The pediatric hospitalist service isa teaching service, with resident andmedical students involved in the careof ∼1100 patients per year. This isapproximately half of all patients admittedto the IPU, with the remainder cared for bypediatric subspecialty or surgical services.During the study period, demographic datawere collected for all pediatric hospitalistpatients discharged from the hospital; 93%were English speaking, 56% had Medicaidcoverage, 18% had complex chronic medicalconditions,11 and the average length of staywas 3.04 days. Interpreter Services providedlive or telephone interpretation fordischarge education, including medicationinstructions, for all non-English speakers.

As part of Project IMPACT, aninterprofessional improvement team usedmonthly plan-do-study-act cycles toimplement a 4-part bundle (including adischarge readiness checklist, teach-backeducation, timely and complete handoffto the primary care provider, and apostdischarge phone call).1 To supportparticipation in Project IMPACT, the hospitalprovided funding for a nurse to performpostdischarge phone calls and a researchassistant to perform chart reviews.

Interventions

In January 2015, MMC opened an outpatientpharmacy in the hospital, open 24 hours perday, 7 days per week, enabling dischargeprescriptions to be filled on-site. Thedecision to open a hospital-owned

outpatient pharmacy was influenced by theshift toward value-based accountable careacross the larger health care organization.The hospital calculated that an outpatientpharmacy could improve patientsatisfaction and outcomes and reducereimbursement penalties for reuseresulting from poor medication adherence.12

As opposed to contracting with a retailpharmacy, a hospital-owned pharmacypresents several advantages, includingaccess to the electronic health record (EHR)for more efficient and accurate medicationreconciliation and provider collaborationacross the care continuum.

Our Project IMPACT team identified this as aunique opportunity to allow patients toleave the hospital with dischargemedications in hand (Fig 1). In December2015, a discharge medication subgroup(including 3 hospitalist physicians, a nursemanager, a pediatric resident, 2 inpatientpediatric pharmacists, and a medicationtransitions pharmacist) formed to furtherfocus on improvement. Additionalinterventions included education outreachto residents, attending and nursingproviders with explanation of the benefits ofdischarging patients with “medications inhand,” emphasizing discharge medicationplanning in daily interdisciplinary carerounds, and EHR optimization. EHRmodifications included routinge-prescriptions to our outpatient pharmacy,creation of a consult to outpatientpharmacy order, and templates fordocumenting discharge medication deliveryand teaching. The consult to outpatientpharmacy order can be entered byphysicians, pharmacists, or nurses andserves to identify a patient requiringdischarge prescriptions, activatemedication preparation, initiate review ofinsurance coverage and requirements (suchas previous authorization), and requestbedside delivery. Supplemental Figure 6depicts a full timeline of interventions.Bedside delivery was primarily performedby outpatient pharmacists who conductedand documented teaching with medicationsin hand. Routine use of the teach-backeducation technique has already beenreliably adopted across our unit as part ofProject IMPACT.1

724 MALLORY et al

by guest on November 27, 2020www.aappublications.org/newsDownloaded from

Study of the Interventions

As part of Project IMPACT, charts arereviewed for all patients discharged fromthe pediatric hospitalist service, includingdocumentation of discharge education andtranscripts from a phone call performedwithin 3 days of discharge.1 With theinitiation of the medication project, weadded a question to the phone call scriptasking whether new medications were filledbefore discharge. Patients not dischargedfrom the hospital were excluded from thestudy. Data are entered into a RedCap13

database designed for the multicentercollaborative with additional elements forsite-specific projects. We tracked patientsatisfaction related to hospital dischargemedication experience from PediatricHospital Consumer Assessment ofHealthcare Providers and Systems (HCAHPS)data, which was adopted in the fourthquarter of 2014. We accessed adult HCAHPSdata from our institution as a comparison.Additionally, for all patients discharged fromour IPU, the outpatient pharmacy trackedthe total number of electronicallyprescribed and written dischargeprescriptions, as well as the percentage ofthose filled at our outpatient pharmacy,

associated with a consult to outpatientpharmacy order, delivered to the bedsideand with documented pharmacist teachings.

Measures

Our primary process measure waspercentage of pediatric hospitalist patientswith new medications filled beforedischarge, with a goal to achieve 70% by18 months. “New” medications weredetermined by using discharge medicationreconciliation fields in our EHR. “Continued”medications or those with dosing changesonly were excluded. Success wasdocumented and tracked by a “yes”response to the question “Were medicationsfilled prior to discharge?” on the dischargereadiness checklist or from EHR dischargemedication reconciliation. A second processmeasure was bedside delivery rates ofmedications prescribed to our outpatientpharmacy (as opposed to being picked upby the family before discharge). Our goalwas to deliver 70% of medicationsprescribed to the outpatient pharmacy tothe bedside.

Outcome measures were percentageanswering “yes, definitely” on PediatricHCAHPS surveys for 2 discharge medication-

related questions (“Before your child left thehospital, did a provider or hospitalpharmacist explain in a way that was easyto understand about the possible sideeffects of these new medications?” and“Before your child left the hospital, did aprovider explain in a way that was easy tounderstand how your child should takethese new medications after leaving thehospital?”). Caregiver ability to verify accessto new medications and successfully teach-back administration instructions wasdetermined at the time of a postdischargephone call and tracked for every patient.We tracked percentage of all IPU dischargesoccurring before noon as a balancingmeasure.

Analysis

Statistical process control charts trackedpercentage of patients with medicationsfilled before discharge, bedside deliveries,consult to outpatient pharmacy orders,and pre-noon discharges with centerlinesused to portray overall averageproportions and 3-s control limits todetect special cause variation. We usedAssociates for Process Improvement rulesfor detecting special cause. Odds ratio(OR) analysis compared caregivers’inability to teach-back medicationadministration instructions at the time ofa postdischarge phone call. Medication-related Pediatric HCAHPS data werecollected and displayed over time. Fisher’sexact test compared adult and pediatricHCAHPS responses in the final quarter ofthe study period.

Ethical Considerations

The MMC Institutional Review Boardconsidered the project to be a local qualityimprovement initiative. Informed consentbeyond standard consent for treatmentwas not required.

RESULTS

Data from 2014 served as a baseline, with829 patients discharged from the hospitalfrom the pediatric hospitalist service, ofwhom 465 (56%) had new medicationsprescribed, with 2% to 9% filled beforedischarge (mainly rectal diazepam or 3-daysupplies of medications dispensed from theinpatient pharmacy in cases in which

FIGURE 1 Key driver diagram.

HOSPITAL PEDIATRICS Volume 7, Issue 12, December 2017 725

by guest on November 27, 2020www.aappublications.org/newsDownloaded from

barriers to timely filling of prescriptionshad been identified). We successfullycontacted 459 (55%) of our 2014 patients viapostdischarge phone call, and 32 (7%) couldnot successfully teach-back medicationadministration instructions.

During the study period, January 2015 toSeptember 2016, 1425 patients weredischarged from the hospital from thepediatric hospitalist service, with 958 (67%)contacted via postdischarge phone call. Ofthe 873 (61%) patients discharged with new

medications, 515 (59%) left the hospital withmedications in hand (Fig 2).

In Fig 3, we display improvement over timefor our primary process measure, withinterpretation of special cause points.Improvement in bedside delivery ofmedications over time is depicted in Fig 4.Coinciding increased use of the consult tooutpatient pharmacy order in the EHR isdisplayed in Supplemental Fig 7.

Random chart review of patients notdischarged with medications in hand wasperformed at the end of the study andrevealed barriers to filling prescriptionsbefore discharge. These includedinadequate planning, resource limitation forbedside delivery, and patient preference.Percentage of discharges from the IPUbefore noon (Supplemental Fig 8) improvedand remained steady with a mean of 51%during the study period, save the final datapoint.

Our first outcome measure in which wetracked patient satisfaction with newmedication side effect teaching wasincluded in both adult and pediatric HCAHPSsurveys. Pediatric improvement for this

FIGURE 2 Discharge medication process and outcomes. * OR 5 0.2052, P 5 .046

FIGURE 3 Statistical process control chart displaying monthly rates of patients leaving the hospital with new medications in hand. Prior tointerventions, a baseline of 2%-9% was observed. After a series of focused interventions, our rate is now 85%. LCL, lower control limit;PHM, pediatric hospital medicine; Rx, prescriptions; UCL, upper control limit.

726 MALLORY et al

by guest on November 27, 2020www.aappublications.org/newsDownloaded from

question with comparative adult data aredisplayed in Fig 5A. Comparison of pediatricand adult satisfaction for the final datapoint showed a statistically significantdifference (88% vs 50%, P 5 .00385,Fisher’s exact test). In Fig 5B, we displayperformance for a more generalmedication-related patient experiencequestion (“staff explained how to take newmedication”) present on the PediatricHCAHPS survey only.

As an additional outcome measure, weperformed subgroup analysis by using datafrom follow-up phone calls to assessaccuracy of medication instruction teach-back. Although rates of successful teach-back were generally high (93% at baseline),families were less able to teach-back newdischarge medication instructions if theydid not have medications in hand at thetime of discharge (Fig 2). Familiesdischarged without medications in handwere inaccurate 3% of the time, whereasfamilies discharged with medications inhand were only inaccurate 0.7% of the time(OR 0.2052, P 5 .046).

DISCUSSION

By optimizing use of an on-site outpatientpharmacy, we increased the percentage ofpediatric hospitalist patients dischargedwith new medications in hand from 2% to85% over the 21-month study period. Keyinterventions to achieve our goal wereformation of an engaged interprofessionalteam with strong pharmacy representation,promotion of a consult to outpatientpharmacy order in the EHR to facilitateearlier discharge preparation, and use ofbedside delivery services with accompaniedpharmacist teaching (Supplemental Fig 9).We hypothesized that discharging pediatricpatients with new medications in handwould facilitate hands-on as opposed toverbal and/or theoretical dischargeteaching and lead to improved medication-related family experience and patient safetyvia increased family understanding ofcorrect medication use. Improvements indischarge medication-related patientsatisfaction survey scores support thatfamily experience improved. The near-universal ability to teach-back discharge

medication instructions at the time of apostdischarge phone call for families whohad prescriptions filled before dischargesupports the enhanced understanding ofmedication use and administrationinstructions, contributing to improvedpatient safety.

Our endeavor consisted of overlappinginterventions (teaching with medication inhand, bedside delivery, and pharmacistteaching), making it difficult to assess whicheffort was most impactful. Additionally,Project IMPACT includes multiple ongoingefforts to improve hospital-to-hometransitions. These certainly benefit ourmedication-focused initiative. For thisreason, we chose medication-specificoutcome measures to try to isolate thispiece of the discharge process, trackingmedication-related HCAHPS scores andmedication-related teach-back during thepostdischarge phone call.

Hatoun et al7 describe a similar initiativetargeted at their pediatric population withasthma that directly measured impact onmorbidity, showing significant decreases in

FIGURE 4 Statistical process control chart displaying monthly rates of patients with prescriptions to our outpatient pharmacy delivered to thebedside. Rates have improved from 28% with the availability of the service to 71% after sequential interventions to optimize use. LCL,lower control limit.

HOSPITAL PEDIATRICS Volume 7, Issue 12, December 2017 727

by guest on November 27, 2020www.aappublications.org/newsDownloaded from

reuse rates for patients discharged withmedications in hand. Because ourpopulation included all diagnoses forpatients discharged from our service, wedid not choose reuse as an outcomemeasure, fearing that with low baselinereadmission rates (4%–7%) we wereunderpowered to detect any difference.Interestingly, they cite 3 strategies key to thesuccess of their project: getting inpatientproviders to write prescriptions earlier inthe admission, improving efficiency ofmedication preparation at their outpatient

pharmacy, and bedside delivery ofmedications. Similarly, our consult tooutpatient pharmacy order in the EHRaddresses all 3 of these strategies and wascritical to our endeavor.

Strong anecdotal support for bedsidedelivery of medications emerged in ourmonthly meetings and is supported byreports from other hospitals.14 This serviceis especially “family-centered” for pediatriccaregivers who may have to coordinatechild care to pick-up prescriptions. Westrongly emphasized use of the delivery

service in each of our plan-do-study-actcycles. The downside of bedside delivery ispotential for discharge delays, so wetracked percentage of unit dischargesbefore noon as a balancing measure.Improving percentage of prenoondischarges suggest that our endeavor didnot lead to significant discharge delays onaverage. The exception is the final quarterof 2016, when rates dropped below thelower confidence limit. The team struggledto explain this decrease, hypothesizing thatJuly house staff turnover may havecontributed. Throughout the study period,we have worked to initiate delivery serviceearlier in the discharge process by usingthe consult order to limit delays in fillingprescriptions, coordinate bedside delivery,and prevent any pharmacy processchallenges. Daily interdisciplinary carerounds provided an opportunity to activatethis order on the day before anticipateddischarge. We identified evening hours as aconvenient time for families to receiveteaching, uninterrupted by rounding teams,testing, or consults. We were eventually ableto obtain support for an additionalpharmacist to work afternoon and/orevening hours. The increase in prescriptionvolume and demand for bedside deliveryhelped to support the additional resources.Other lessons learned included establishinga pathway for families to transferprescription refills to their local pharmacyor arrange refills by mail from ourpharmacy. As a children’s hospital within anadult hospital, we were able to use adultHCAHPS responses as an internal control.Although adult patients had access to theoutpatient pharmacy resource, with a largernumber of patients and care teams, theywere not subject to the same medication-targeted improvement project. Thepediatric-specific improvements, especiallyin the side effect–related HCAHPS question,support that our successful outcomes werelinked to collaborative interventions asopposed to simply access to the outpatientpharmacy.

The improved scores involving caregiverability to teach-back medicationadministration instructions representimproved understanding for patientsdischarged with medications in hand.

FIGURE 5 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)Patient Experience Data displayed by calendar quarter. A, HCAHPS: staff explainedmedicine side effects; B, HCAHPS-P: staff explained how to take new medicine. Qtr,quarter.

728 MALLORY et al

by guest on November 27, 2020www.aappublications.org/newsDownloaded from

However, we noted improvement frombaseline even in patients dischargedwithout medications in hand (7%–3%).This is likely due to more global, ongoingimprovement efforts with Project IMPACT toimplement a pediatric hospital-to-hometransitions bundle. Specifically, the inclusionof teach-back as a discharge educationstrategy for all instructions (includingmedications) may result in a higher degreeof understanding, even for patients who filltheir medications after discharge. Anotherlimitation of that outcome measure is itsreliance on successful phone contact. Likeother published reports of postdischargephone calls, we failed to connect with justover 30% of our patients.15 This limits ourability to generalize from phone call data.In fact, we hypothesize that patients we donot reach may be more vulnerable tomisunderstanding because phone contactis contingent on phone access andcaregiver availability, both of which canbe challenges for socioeconomicallydisadvantaged populations.

Another limitation of our study is thatsuccesses are potentially contextdependent. Availability of the on-site,outpatient pharmacy was critical to thesuccess of our project, as was our stronginterprofessional partnership and engagedgroup of inpatient and outpatientpharmacists. Although it is costly to open anoutpatient pharmacy, some costs can beoffset by increasing prescription volume.Providing employee prescriptions,discharge prescriptions, outpatient clinicpatient services, and specialty pharmacyprograms all contribute to volume.Additionally, with only 40% of hospital patientscovered by private insurance, our organizationqualified for the federal 340B Drug PricingProgram, which requires drug manufacturersto sell outpatient medications to eligiblehealth care organizations at a reduced cost.These cost savings improve profit marginsand benefit indigent or underinsured patientswho otherwise could not afford necessarymedications.

Although smaller hospitals or exclusivelychildren’s hospitals may not be able tosupport a similar financial proposal to openan on-site outpatient pharmacy, Sauers-Ford

et al16 describe a successful medications inhand discharge project for pediatricpatients with asthma that uses a localpharmacy partnership, suggesting thatdischarge with medications in hand couldbe possible in most settings. A plannednext step of this project is to test dischargewith medications in hand across severalhospitals from Project IMPACT. If successful,this will further support that successes arenot context specific or dependent onavailability of an on-site outpatient pharmacy.

Unit-wide buy-in has been excellent for theproject, and our rates of new dischargemedications filled before dischargecontinue to increase as shown in Fig 3. Unit-based culture now results in discharge withmedications in hand unless there is aspecific reason not to, such as familypreference, suggesting that the process hascrossed a sustainability threshold. With thisin place, the next steps include comparingpatient experience and outcomes with nurseversus pharmacist discharge medicationteaching, attempting to measure impact onmorbidity more directly with high-riskpopulations, and performing a cost-analysisof the program.

Acknowledgments

None of the work could have occurredwithout support from our outpatientpharmacists: Jaimie Charron, OwenTheriault, Bill Hewitt, Teegan French, PeterO’Gagnon, Jim Leonetti, Diana Tsai- Leonard,and Linh Dang; the other members of ourhospital-to-home transitions improvementteam: Kelly Anctil, Jonathan Bausman,Aggie Bellevue, Shannon Bennett, AbihijitBhattacharyya, Nancy Bouthot, SarahBunting, Danielle DiCesare, JenniferHayman, Jennifer Jewell, Nicole Manchester,Anna Martens, Teresa Morgan, JoelMcMullin, Elizabeth Murphy, Logan Murray,Steve Prato, Brandy Robertson, Clare Ronan,Ina St. Onge, Matthew St Onge, and SusanTalbot; the Project IMPACT Pilot Site Leaders:David Cooperberg, Snezana Osorio, andSandra Gage; and Wendy Craig for dataanalysis support.

REFERENCES

1. Mallory LA, Osorio SN, Prato BS, et al;IMPACT Pilot Study Group. Project IMPACT

pilot report: feasibility of implementinga hospital-to-home transition bundle[published correction appears inPediatrics. 2017;139(6):e20170816].Pediatrics. 2017;139(3):e20154626

2. Auger KA, Simon TD, Cooperberg D,et al. Summary of STARNet: SeamlessTransitions and (Re)admissionsNetwork. Pediatrics. 2015;135(1):164–175

3. Wu S, Tyler A, Logsdon T, et al. A qualityimprovement collaborative to improvethe discharge process for hospitalizedchildren. Pediatrics. 2016;138(2):e20143604

4. Kripalani S, Price M, Vigil V, Epstein KR.Frequency and predictors ofprescription-related issues afterhospital discharge. J Hosp Med. 2008;3(1):12–19

5. Yin HS, Parker RM, Sanders LM, et al.Liquid medication errors and dosingtools: a randomized controlledexperiment. Pediatrics. 2016;138(4):e20160357

6. Gattari TB, Krieger LN, Hu HM,Mychaliska KP. Medication discrepanciesat pediatric hospital discharge. HospPediatr. 2015;5(8):439–445

7. Hatoun J, Bair-Merritt M, Cabral H,Moses J. Increasing medicationpossession at discharge for patientswith asthma: the meds-in-hand project.Pediatrics. 2016;137(3):e20150461

8. Kenyon CC, Rubin DM, Zorc JJ, Mohamad Z,Faerber JA, Feudtner C. Childhoodasthma hospital discharge medicationfills and risk of subsequent readmission.J Pediatr. 2015;166(5):1121–1127

9. Budiman T, Snodgrass K, Komatsu Chang A.Evaluation of pharmacist medicationeducation and post-discharge follow-upin reducing readmissions in patientswith ST-segment elevation myocardialinfarction (STEMI). Ann Pharmacother.2016;50(2):118–124

10. Schillinger D, Piette J, Grumbach K,et al. Closing the loop: physiciancommunication with diabetic patientswho have low health literacy. Arch InternMed. 2003;163(1):83–90

HOSPITAL PEDIATRICS Volume 7, Issue 12, December 2017 729

by guest on November 27, 2020www.aappublications.org/newsDownloaded from

11. Simon TD, Cawthon ML, Stanford S, et al;Center of Excellence on Quality of CareMeasures for Children With ComplexNeeds (COE4CCN) Medical ComplexityWorking Group. Pediatric medicalcomplexity algorithm: a new method tostratify children by medical complexity.Pediatrics. 2014;133(6). Available at: www.pediatrics.org/cgi/content/full/133/6/e1647

12. Fox D. Four reasons why a hospitalshould open an integrated pharmacy.Managed Healthcare Executive Web site.2016. Available at: http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/four-

reasons-why-hospital-should-open-integrated-pharmacy. Accessed June 15,2017

13. Harris PA, Taylor R, Thielke R, Payne J,Gonzalez N, Conde JG. Researchelectronic data capture (REDCap)–ametadata-driven methodology andworkflow process for providingtranslational research informaticssupport. J Biomed Inform. 2009;42(2):377–381

14. Knoer S. Leveraging the pharmacyenterprise to improve the patientexperience. Association for PatientExperience Web site. 2014. Available at:

www.patient-experience.org/Resources/Newsletter/Newsletters/Articles/2014/Leveraging-the-Pharmacy-Enterprise-to-Improve-the.aspx. Accessed June 14,2017

15. Heath J, Dancel R, Stephens JR.Postdischarge phone calls afterpediatric hospitalization: anobservational study. Hosp Pediatr. 2015;5(5):241–248

16. Sauers-Ford HS, Moore JL, Guiot AB,et al. Local pharmacy partnership toprevent pediatric asthma reutilization ina satellite hospital. Pediatrics. 2016;137(4):e20150039

730 MALLORY et al

by guest on November 27, 2020www.aappublications.org/newsDownloaded from

DOI: 10.1542/hpeds.2017-0053 originally published online November 7, 2017; 2017;7;723Hospital Pediatrics 

Jessica L. Miller, Nancy M. Nystrom, Melanie R. Lord and Lorraine L. McElwainLeah A. Mallory, Noah P. Diminick, Jonathan P. Bourque, Meredith R. Bryden,

Discharge Medication ProcessPediatric Patient-Centered Transitions From Hospital to Home: Improving the

ServicesUpdated Information &

http://hosppeds.aappublications.org/content/7/12/723including high resolution figures, can be found at:

Supplementary Material

2017-0053.DCSupplementalhttp://hosppeds.aappublications.org/content/suppl/2017/11/03/hpeds.Supplementary material can be found at:

Referenceshttp://hosppeds.aappublications.org/content/7/12/723#BIBLThis article cites 13 articles, 8 of which you can access for free at:

Subspecialty Collections

rovement_subhttp://www.hosppeds.aappublications.org/cgi/collection/quality_impQuality Improvementdicine_subhttp://www.hosppeds.aappublications.org/cgi/collection/hospital_meHospital Medicinef_care_transition_-_discharge_planning_subhttp://www.hosppeds.aappublications.org/cgi/collection/continuity_oContinuity of Care Transition & Discharge Planningon:practice_management_subhttp://www.hosppeds.aappublications.org/cgi/collection/administratiAdministration/Practice Managementfollowing collection(s): This article, along with others on similar topics, appears in the

Permissions & Licensing

mlhttp://www.hosppeds.aappublications.org/site/misc/Permissions.xhtin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.hosppeds.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

by guest on November 27, 2020www.aappublications.org/newsDownloaded from

DOI: 10.1542/hpeds.2017-0053 originally published online November 7, 2017; 2017;7;723Hospital Pediatrics 

Jessica L. Miller, Nancy M. Nystrom, Melanie R. Lord and Lorraine L. McElwainLeah A. Mallory, Noah P. Diminick, Jonathan P. Bourque, Meredith R. Bryden,

Discharge Medication ProcessPediatric Patient-Centered Transitions From Hospital to Home: Improving the

http://hosppeds.aappublications.org/content/7/12/723located on the World Wide Web at:

The online version of this article, along with updated information and services, is

http://hosppeds.aappublications.org/content/suppl/2017/11/03/hpeds.2017-0053.DCSupplementalData Supplement at:

Print ISSN: 1073-0397. Illinois, 60143. Copyright © 2017 by the American Academy of Pediatrics. All rights reserved. published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca,publication, it has been published continuously since 1948. Hospital Pediatrics is owned, Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly

by guest on November 27, 2020www.aappublications.org/newsDownloaded from