How Can my Pharmacy Support Care Coordination for LTC@H Patients?

EVIDENCE TYPE

Documented care coordination communications in patient record · Prescriber outreach log · Medication reconciliation updated at each transition · Evidence of coordination with home health or other care team members

Audience

Pharmacists, pharmacy owners, pharmacy technicians

In institutional LTC, care coordination happens within the facility — nurses, physicians, pharmacists, and social workers share information in the same building. For LTC@H patients, this infrastructure does not exist. The pharmacy is the one constant touchpoint across all care settings — the patient fills their medications at your pharmacy whether they are at home, returning from hospital, or transitioning between providers. This position gives you both the opportunity and the obligation to serve as a coordination hub: flagging transitions, reconciling medications after changes, and communicating proactively with the care team when something in the patient's regimen signals a clinical concern. This is what S10 requires, and it is what separates LTC@H pharmacy from retail dispensing.

• The pharmacy must have a documented process for identifying and responding to care transitions — hospital admissions, discharges, provider changes, and changes in care setting
• Medication reconciliation must be updated at each transition event
• Clinically significant changes identified during a transition must be communicated to the prescribing provider in writing
• Care coordination activities must be documented in the patient record

Hospital discharge

• Hospital discharge is the highest-risk transition for LTC@H patients — medication lists frequently change during a hospitalization and new prescriptions are not always communicated to the pharmacy
• At discharge notification: request the hospital discharge medication list, reconcile it against your dispensing record, identify any additions, changes, or discontinuations, and contact the prescriber to confirm the current regimen before the next fill
• Document the reconciliation and all communications in the patient record

Prescriber changes

• When an LTC@H patient changes their primary care provider, the new prescriber may not have the full medication history — proactively send the current medication reconciliation to the new provider
• Request confirmation that the new prescriber has reviewed the current regimen and is continuing all existing orders

Caregiver changes

• A change in the primary caregiver is a coordination risk — the new caregiver may not know the patient's medication routine, compliance packaging use, or PRN protocols
• Conduct a medication administration education session with the new caregiver and document it

Changes in care complexity

• If a patient's regimen significantly increases in complexity — new diagnoses, added medications, increased injection or infusion needs — this is a trigger to reassess the level of coordination needed and communicate proactively with the care team

• A documented care coordination policy or protocol on file
• Patient record entries at each transition event showing reconciliation and outreach
• Written communications to prescribers at each transition, with delivery confirmation
• Updated medication reconciliation reflecting post-transition regimen

1. Establish a transition monitoring process — at minimum, track hospitalizations and discharges for all active LTC@H patients by maintaining a log and following up at each known transition
2. Create a transition reconciliation checklist: request discharge medication list, compare to dispensing record, identify changes, confirm with prescriber, update patient record
3. Standardize your written prescriber communication for transitions — use the Physician Notification format and adapt it for post-transition use
4. Document every coordination activity in the patient record at the time it occurs
5. At each annual review, assess whether the coordination touchpoints you documented match the transitions the patient actually experienced

• Waiting for the patient or caregiver to report a hospitalization — by the time they call the pharmacy, a week or more may have passed. Build proactive tracking into your workflow
• Reconciling only new prescriptions issued at discharge rather than the full medication list — discharge prescriptions often include discontinuations that are not explicitly communicated
• Not documenting coordination activities because they seem routine — every prescriber communication and reconciliation update must be in the patient record
  

When Care Coordination Should Occur

• At the start of Long Term Care Pharmacy at Home services
• With each MDR or patient care cycle
• After any care transition (hospital, SNF, hospice)
• Upon significant medication changes
• When adherence issues arise
• At provider or caregiver request

Best Practices for Care Coordination

• Use standardized templates for documenting communication and MDR findings.
• Integrate care coordination tasks into the dispensing and refill workflow.
• Establish clear escalation protocols for urgent clinical issues.
• Build relationships with local healthcare providers to streamline collaboration.
• Provide regular staff training on care coordination responsibilities and documentation standards.