Continuum of Care

Pre-Admission Medication Review (for New Residents): Before a new resident arrives at your personal care home or assisted living, our team swings into action to prepare on the pharmacy front. With your permission, we’ll coordinate with the discharging entity (hospital, rehab, or previous home pharmacy) to obtain the resident’s current medication list and orders . Our consultant pharmacist then performs a Pre-Admission Regimen Review (PRE) – a thorough check of all medications for appropriateness in the long-term care setting, potential interactions, and cost impact . We look at dosing schedules to see if they can be simplified (e.g., can a med be given once daily instead of twice?), review for any high-risk drugs that might need closer monitoring, and ensure we can provide everything needed. By doing this:

• We catch issues early – for instance, if the resident is on a medication not on their Part D plan, we identify a solution upfront rather than you discovering at the first pharmacy bill.
• We ensure all medications will be ready on Day 1. Our goal is that by the time the resident is moving in, we have their medication regimen completely verified, entered into our system, and initial cycle fill prepared for delivery . No waiting around for a physician order to come through or emergency first doses – it’s all in place.
• We communicate with you and the prescriber any recommendations. For example, our pharmacist might suggest “Resident is on Drug X which is very costly and similar to Drug Y; consider switching.” Or “We recommend a therapeutic interchange to a different proton pump inhibitor that’s on formulary.” These suggestions are provided for physician approval prior to admission. Often, by making a tweak or two, we can prevent a lot of headache later (like preventing duplicate therapies or medications that conflict with facility policies).

By the time the new resident arrives, you and your staff can be confident that their med routine will start off on the right foot with no lapses. This makes the admission process far less nerve-wracking for your nurses and the resident’s family. HealthDirect’s data shows admissions can be stress-free when pharmacies take these steps – we emulate that proven approach.

During Facility Stay (Maintaining Continuity): If a resident needs to go out to an appointment or short hospital visit, we help maintain continuity by providing leave-of-absence medication packs. For instance, if a resident goes to a specialist for the day and needs to take a dose while out, we can package a special dose pack for them to carry. For longer LOAs or hospitalizations, we ensure that when they return, their meds at the facility resume correctly. We reconcile any medication changes from a hospital stay as soon as we get the discharge orders, working with your staff to update MARs and supply new meds.

Additionally, our consultant pharmacist participates in care plan meetings or transitional care meetings for residents as needed (especially if the resident has complex medication issues). We can attend virtually or in person to provide input on medication-related concerns during care transitions, such as plans to taper certain meds or monitoring needed when a resident’s level of care changes.

Discharge Planning and “Meds to Go”: When a resident is leaving your facility (returning home or moving to another setting), we offer a Delivery at Discharge program to set them up for success at home . This includes:

• Filling up to a 30-day supply of all their medications right before discharge, and delivering it to the facility or the resident’s home on the day of discharge . This way, they leave with everything they need – no immediate trip to a retail pharmacy required when they get home. We coordinate with the discharging nurse or social worker to get the final med list and any new scripts, and have those ready.
• Providing educational counseling to the resident (and family) on their medications before they leave. Our pharmacist can do this in person if local, or via a secure video call (FaceTime, etc.) as HealthDirect described . We’ll explain any changes in layman’s terms and ensure they know what each medication is for, how to take it, and answer any questions. This counseling is crucial in reducing confusion and errors once they’re on their own or under family care.
• Follow-up Support: After discharge, we don’t just cut them off. We offer follow-up calls at intervals (for example, 3 days, 10 days, 20 days post-discharge) to check adherence and address any issues . If we identify a problem – say the resident stopped a medication due to side effects – we can loop in their physician or home care nurse. These follow-ups can significantly reduce the chance of re-hospitalization by catching issues early . While this level of follow-up is above-and-beyond traditional pharmacy, we believe it’s part of being a true care partner and gives your facility a quality advantage to boast about (reduced readmissions, better patient satisfaction).

Collaboration with Home Health and PCPs: If a resident is going home with home health services, we coordinate with those providers as well. We can supply a Medication Administration Record for the home health nurse listing all current meds, to avoid transcription errors. For residents who will continue with Custom Care as their outpatient pharmacy (we do service individuals at home too), we ensure a seamless transition to our retail/community pharmacy side, so there’s no break in service. They can keep getting adherence packaging (our Care Pack) and delivery at home if desired . This continuum – from facility to home – means continuity for the patient and ongoing business for us, truly a win-win.

Regulatory Compliance: Our continuum services also help you meet any regulatory expectations regarding transitions. For instance, personal care homes in PA must provide a complete list of medications and ensure discharge meds are arranged. Our process helps you check those boxes thoroughly. Also, by preventing medication errors at transitions, we help protect your quality metrics and reputation.

In summary, Custom Care’s Continuum of Care consulting wraps residents in a safety net during transitions. We hear the challenges you face in admissions and discharges – and we’ve developed solutions to remove that burden from you . The outcome is seamless care: residents get what they need without gaps, families feel supported, and your staff can breathe easier knowing a critical aspect of transitions – the meds – are under expert control. We stand by you from start to finish, because caring for residents is not a confined episode for us; it’s an ongoing journey we take together, through every handoff and change along the way