OBJECTIVE: Geriatric patients are more sensitive to medications and are at risk for polypharmacy, requiring a medication review. It is hypothesized that a justin-time message to the primary care provider (PCP) recommending a change to potentially inappropriate medications may increase the rate of acceptance of pharmacist recommendations.<br/> DESIGN: Prospective, quality improvement study.<br/> SETTING: Health-system-based primary care facilities.<br/> INTERVENTIONS: Providers were contacted two business days prior to the patient's appointment with a recommendation based on a Beers criteria-derived algorithm. If a PCP was colocated with a pharmacist in the clinic, the preferred method of communication was queried.<br/> PATIENTS, PARTICIPANTS: Medical records of patients 65 years of age or older enrolled in the Johns Hopkins Medicine Alliance for Patients Accountable Care Organization were evaluated for tricyclic antidepressant use in neuropathy, insomnia, and depression; and benzodiazepine use in anxiety and insomnia if prescribed by the PCP.<br/> MAIN OUTCOME MEASURE: The primary outcome was to determine the number of recommendations accepted by the PCP.<br/> RESULTS: A total of 252 recommendations were made with a total of 26.2% recommendations being accepted (22.1% for benzodiazepines and 22.7% for tricyclic antidepressants). Of the 26.2% of recommendations accepted, 56% had a pharmacist in the clinic. A total of 96.7% of PCPs preferred a message to be sent through the patient's medication record.<br/> CONCLUSION: A just-in-time approach in making recommendations to PCPs was successful in leading to medication changes. There was no statistical difference between physician acceptance of pharmacist recommendations in relation to a pharmacist being embedded in the clinic.