Pharmacist Clinical Interventions and Discharge Counseling in Medical Rehabilitation Wards in a Local Hospital: A Prospective Trial

Patients undergoing rehabilitation experience numerous changes in medication regimens during care transitions, exposing these patients to an increased risk of drug-related problems (DRPs). A prospective, non-randomized, quasi-experimental study was conducted in medical rehabilitation wards to evaluate the impact of pharmacist-delivered interventions and counseling on 30-day unplanned health care utilization and medication adherence for selected rehabilitation patients. A pharmacist provided medication reconciliation and counseling before discharge. Phone follow-up was completed 30 days after discharge to assess for unplanned health care utilization rate and medication adherence. A total of 85 patients (n = 43 in prospective intervention group and n = 42 in historical usual care group) were included. Among the intervention group, 23 DRPs were identified in 14 (32.6%) patients, resulting in 51 interventions. The intervention group had a significantly lower unplanned health care utilization rate than the usual care group (25.6% vs. 47.6%, p = 0.035). The risk of unplanned health care utilization was reduced by over 60% (Odds ratio (OR) = 0.378; 95% CI = 0.15-0.94). Patients reporting medium to high medication adherence increased from 23.6% to 88.4% 30 days after counseling (p < 0.05). Pharmacist medication reconciliation and discharge counseling reduced unplanned health care utilization 30 days after discharge and improved medication adherence.