Challenges in posthospital care: nurses as coaches for medication management.

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.