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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

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.

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.