Post-Discharge Medication Reconciliation and Support
Your Role — Nurse
Patient's Home (Home Visit)
You are a community nurse making a post-discharge visit to an 82-year-old patient who was discharged from hospital three days ago following a fall and subsequent hip fracture repair. The patient was discharged with five new medications. The patient lives alone and has mild cognitive impairment. A neighbour has been helping with shopping.
- •Confirm the patient's understanding of why they were in hospital and what surgery they had. Assess how they are managing at home.
- •Review all medications with the patient — identify what they are taking, when, and if there have been any problems (missed doses, confusion, side effects).
- •Reconcile discharge medications with any pre-existing medications. Clarify any discrepancies or changes.
- •Provide a clear, written medication schedule in large print. Use teach-back to confirm understanding (e.g., 'Can you show me which tablet you take in the morning?').
- •Assess home environment (mobility aids, bathroom safety, trip hazards, food availability). Arrange additional support if needed (meals on wheels, community alarm, GP follow-up). Establish patient's consent for ongoing visits.
The Interlocutor
Played by the actor / assessor
You are 82 years old and live alone. You were in hospital after falling and breaking your hip. You had surgery and came home three days ago. A neighbour helps with shopping. You're finding it hard to keep track of all the new tablets you've been given.
- •When asked, say you know you had a hip operation but you're not really sure why — you just remember falling in the kitchen.
- •Say you've got all these new tablets and you're not sure which ones to take or when. You've been taking the ones you were already on before hospital but you're not sure about the new ones.
- •When asked, show confusion about the blister pack — you haven't been using it because you're not sure how it works.
- •Say you're managing okay but you're finding it hard to cook and get around the house. You've been using a walking stick but it's difficult.
- •Say you'd appreciate some help with the tablets and someone to check on you regularly.
Sample Role-play
Hello Mr Thompson. I am Jane the community nurse. Your GP asked me to visit after your hospital stay. How are you settling in at home?
Not too bad but I am confused about all these tablets I have been given.
That is very common after a hospital stay especially when medications have been changed. Can you bring me all your medications — both the old ones from before and the new ones from the hospital? Let us sort through them together.
I have got them all in a bag. I am not sure which ones to take now.
What if I forget to take a dose?
Let me take a look. I can see the hospital has provided a blister pack. Each compartment has the day of the week and the time printed on it. Can you show me which tablets you took this morning?
Take it as soon as you remember unless it is nearly time for the next dose. In that case skip the missed dose. Never double up. The dosette box prevents this.
I did not take any this morning. I was not sure which ones were right so I just did not take anything.
I am glad you told me the truth. That is very important. Skipping doses can be risky but taking the wrong ones is more dangerous. Let me identify each tablet for you. This small white one is your blood pressure tablet — take one every morning. This blue one is a new antibiotic. You need to finish the course. Take it with food three times a day for seven days.
I was supposed to finish the antibiotics? The hospital did not tell me that.
I am sorry that was not explained clearly. Yes it is very important to finish the full course of antibiotics even if you feel better to make sure the infection is completely gone. I also notice you have your old blood pressure tablets from before. The hospital has changed your blood pressure medication. Please do not take the old ones anymore. I will contact your GP to confirm the changes.
I would not have known which ones to stop. I probably would have taken both.
That is exactly why I am here — to catch these things. I will also arrange a dosette box for you which a pharmacist will fill weekly. Each compartment has the right tablets for each day and time so you do not need to sort them yourself. You also mentioned finding it hard to get around the house since your fall. Can you tell me more about that?
I have been using a walking stick but I am struggling with the bathroom. There are no grab rails and I am worried about falling again.
I can refer you to the occupational therapy service. They will assess your home and can arrange grab rails for the bathroom a raised toilet seat and a shower chair if needed. This will make your home safer and help you maintain your independence. Would you like me to arrange that?
Yes please. That would put my mind at ease.
I will arrange that today. Let me summarise our plan. One take the antibiotic three times a day with food until finished. Two stop the old blood pressure tablets take only the new ones. Three I will arrange a dosette box. Four OT will contact you about bathroom equipment. I will visit again next week to check how you are getting on. Any questions?
No you have been very helpful. Thank you Jane.
You are welcome. Here is my card. Call me if you have any questions before my next visit.
Can I take painkillers with the new tablets?
Paracetamol is safe but avoid ibuprofen while on the new blood pressure medication. I will write a compatibility list for you.
How long before I can drive again?
Useful Phrases
Clinical Background
Post-discharge medication reconciliation is critical for elderly patients with polypharmacy and cognitive impairment. Risk factors: multiple medication changes during admission, lack of family support, language barriers, visual impairment. Use of blister packs, large-print labels, and community pharmacist involvement reduces readmission risk. Always use teach-back to confirm understanding.
Common Mistakes to Avoid
- ✕Assuming the patient understands the discharge summary — always verify using teach-back.
- ✕Not checking whether the patient has stopped old medications that were discontinued in hospital.
- ✕Focusing only on medications without assessing the broader home environment and support needs.