MTM Transitions of Care & Reconciliation 5 — Questions and Answers
Question 1: A pharmacist performing a post-discharge MTM visit identifies that the patient's primary care physician (PCP) was never notified of new medications started during hospitalization. This failure represents a breakdown in:
- Patient education documentation
- Care team communication and handoff (Correct answer)
- Pharmacy benefit management
- Prior authorization processing
Correct answer: Care team communication and handoff
Failure to communicate discharge medication changes to the PCP is a critical handoff communication breakdown that endangers continuity of care.
Question 2: A patient on warfarin is transitioning from hospital to home. The safest protocol includes all of the following EXCEPT:
- Scheduling an INR check within 3-5 days of discharge
- Educating the patient on signs of bleeding
- Automatically resuming the pre-hospitalization warfarin dose without assessment (Correct answer)
- Confirming the patient has access to their warfarin prescription
Correct answer: Automatically resuming the pre-hospitalization warfarin dose without assessment
Warfarin dosing post-hospitalization requires reassessment, not automatic resumption, because clinical factors may have changed during the hospital stay.
Question 3: In the context of care transitions, 'medication reconciliation' is BEST defined as:
- Counting pills to verify a patient's supply matches their prescription
- The process of comparing a patient's medication orders to all medications the patient has been taking to avoid errors (Correct answer)
- Adjusting medication doses based on the patient's insurance formulary
- Switching brand-name drugs to generic equivalents at discharge
Correct answer: The process of comparing a patient's medication orders to all medications the patient has been taking to avoid errors
Medication reconciliation is the formal process of comparing ordered medications against the patient's complete medication list to identify and resolve discrepancies.
Question 4: A pharmacist is developing a transitions of care program for patients with heart failure. Which intervention has the STRONGEST evidence for reducing 30-day readmissions?
- Sending a written letter to the patient's cardiologist only
- Providing a phone-based follow-up call within 72 hours of discharge combined with a medication review (Correct answer)
- Scheduling a follow-up appointment at 30 days post-discharge
- Mailing a medication list to the patient's home
Correct answer: Providing a phone-based follow-up call within 72 hours of discharge combined with a medication review
Early phone follow-up combined with medication review within 72 hours of discharge has the strongest evidence base for reducing heart failure readmissions.
Question 5: A patient transitioning from ICU to general floor care has their vancomycin dose held by the floor nurse because it was not re-ordered in the new unit's system. This is an example of which type of transition error?
- Therapeutic substitution
- Order omission due to inadequate handoff in the medication reconciliation process (Correct answer)
- Intentional deprescribing
- Pharmacokinetic dose adjustment
Correct answer: Order omission due to inadequate handoff in the medication reconciliation process
Failure to transfer active medication orders during intra-hospital transitions is an omission error resulting from inadequate medication reconciliation during the handoff.
Question 6: Which of the following statements about the role of pharmacists in care transitions is MOST accurate according to MTM best practices?
- Pharmacists should limit their role to verifying prescriptions at the pharmacy counter
- Pharmacists are uniquely positioned to lead medication reconciliation and patient education across care settings (Correct answer)
- Pharmacist involvement in care transitions is optional and not associated with improved outcomes
- Only clinical pharmacists with inpatient privileges can perform medication reconciliation
Correct answer: Pharmacists are uniquely positioned to lead medication reconciliation and patient education across care settings
MTM standards recognize pharmacists as key leaders in medication reconciliation and patient education during care transitions, with evidence showing improved outcomes.
Question 7: A patient takes pantoprazole 40 mg daily at home. During hospitalization, they were switched to famotidine 20 mg BID (formulary substitution). At discharge, neither drug was listed. This scenario represents:
- Appropriate deprescribing of acid suppression therapy
- A complete omission of acid suppression therapy due to reconciliation failure (Correct answer)
- A therapeutic duplication
- An intentional switch back to the patient's home regimen
Correct answer: A complete omission of acid suppression therapy due to reconciliation failure
Neither the home drug nor the inpatient substitute was included at discharge, creating a complete omission of an indicated therapy due to reconciliation failure.
MTM Transitions of Care & Reconciliation 5
A pharmacist performing a post-discharge MTM visit identifies that the patient's primary care physician (PCP) was never notified of new medications started during hospitalization.
This failure represents a breakdown in: