Effect of a trAnSitional Pharmacist Intervention in geRiatric Inpatients on Hospitals Visits After dischargE

"1. Assessing patient and caregiver preferences~2. Medication reconciliation on admission~3. Performing a comprehensive medication review before discharge~4. Promoting safe transition~4.a. Compiling a patient friendly medication list~4.b.Optimizing communication with healthcare providers in primary care:~4.b.i.Providing a copy of the medication list for the community pharmacist~4.b.ii. Contacting the general practitioner by phone~4.b.iii. Contacting, if applicable the home care nurse or the nurse from the nursing home by phone.~5.A motivation interview will take place before discharge with patients and caregivers~6.Post-discharge follow-up: 6.a.Follow-up call to discuss potential drug therapy issues, therapy adherence and to resolve any pending issues 6.b.A telepharmacology service will be provided to primary healthcare professionals as a means to consult the ward-based clinical pharmacists and/or research team after discharge."