I am a Chronic Care Coordinator and partner with Primary Care Providers in chronic care management. Our patients have multiple chronic medical conditions. This care team provides care for patients ranging in age from 18- 75. We facilitate transitions of care between departments and external providers. Patient education is promoted for self care management. Care Coordinators review charts on patients who recently were discharged from hospital and who are in need of a telephonic hospital outreach. This outreach call helps the patient coordinate a medication care plan. A review of their medications upon discharge is verified and the medications they were instructed to stop. However, what we often find is that patients have not been given the correct names of medications or the patient gave the medical staff the correct name but the wrong time frame they have been taking the medication. Frequently the patients have failed to mention over the counter herbal medications that interfere with the reaction for many drugs. Patient education regarding their medications should cover questions as to purpose, dose, and administration time. Pending the outcome of the review we may find different compliance’s that may hinder them taking their medications with factors such as vision, education and finances. A referral to a home care service visit by a RN or an additional office visit for further education regarding medication management, screening for cognitive ability and depression, greatly increases prescription effectiveness.
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