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Challenges in Posthospital Care: Nurses as Coaches for Medication Management

Costa, Linda L. PhD, RN, NEA-BC; Poe, Stephanie S. DNP, RN; Lee, Mei Ching MS, BSN

Journal of Nursing Care Quality:
doi: 10.1097/NCQ.0b013e31820e1543

The purpose of this study was to evaluate a transitional care intervention posthospital discharge for chronically ill medical patients managing complex medication regimens. This descriptive pilot study tested 2 interventions: telephone follow-up and a home visit. Registered nurses delivered the interventions with consulting pharmacist support. Findings included 62% more medication discrepancies discovered during home visit than detected by telephone interview. This brief intervention identified significant knowledge gaps in self-management of discharge medications in the inner city population.

Author Information

The Johns Hopkins Hospital (Drs Costa, Poe), Johns Hopkins University School of Nursing (Dr Costa and Ms Lee), Baltimore, Maryland.

Correspondence: Linda L. Costa, PhD, RN, NEA-BC, The Johns Hopkins Hospital, Johns Hopkins University School of Nursing, 600 N Wolfe St, Billings Adm 205A, Baltimore, MD 21287 (

Funding Information: Partial support was provided by Robert Wood Johnson Foundation, INQRI (Interdisciplinary Nursing Quality Research Initiative).

The authors thank Leigh Efird, PharmD; Leonard Feldman, MD; E. Robert Feroli, PharmD; Kevin Frick, PhD; Redonda Miller, MD, MBA; Terry Nelson, MSN, RN; Michelle Silas, MPH, BSN, RN; and Melissa Vista, BSN, RN, in the development of the pilot study.

Accepted for publication: January 10, 2011

© 2011 Lippincott Williams & Wilkins, Inc.