Reconciliation of Medication Counseling by Pharmacists for Improving Outpatient Adherence:  A Review

Year: 2025; Volume: 5; Issue: 1; Page No: 10 – 13

Article Type: Review Article

Authors:  Nisha Newar1*, Preeti Kumari2, Chitamala Das3

https://doi.org/10.55349/ijmsnr.2025511013

Affiliations: 

1Nursing supervisor and Quality Nurse, Raj Hospital: Super Specialty Hospital, Ranchi, Jharkhand, India.

2Deputy Nursing Superintendent, Raj Hospital: Super Specialty Hospital in Ranchi, Jharkhand, India.

3Cardiac technician, Max hospital, Gurgaon, Delhi, India.

How to cite this article:  Newar N, Kumari P, Das C.  Reconciliation of Medication Counseling by Pharmacists for Improving Outpatient Adherence:  A Review.  Int J Med Sci and Nurs Res 2025;5(1):10–13.     DOI: 10.55349/ijmsnr.2025511013

Corresponding Author:

Mrs. Nisha Newar,

Nursing supervisor and Quality Nurse,

Raj Hospital,

Super Speciality Hospital,

Ranchi, Jharkhand, India.

Email ID: nishanewar98@gmail.com

Article Summary: Submitted: 17-January-2025    Revised: 29-January-2025      Accepted: 28-February-2025     Published: 31-March-2025

Abstract

Background: Medication adherence is crucial in managing chronic and acute diseases, particularly in outpatient settings. However, non-compliance remains a significant issue, leading to adverse health outcomes and increased healthcare costs. Pharmacists play a vital role in overcoming these challenges through medication counselling and reconciliation.

Materials and Methods:  a systematic search of relevant literature was conducted using electronic databases including PubMed, Google Scholar, Scopus, and Science direct. Articles focused solely on inpatient or hospital-based settings without outpatient follow-up.

Results: This review explores the effectiveness of pharmacist-led interventions in outpatient settings, focusing on counselling, medication reconciliation, post-discharge counselling, and their impact on adherence. Pharmacists ensure that patients understand their medications, reducing errors and improving health outcomes. Key strategies such as motivational interviewing, patient education, and technology integration contribute to enhanced adherence rates and fewer medication discrepancies.

Conclusion: Pharmacist-led medication adherence programs significantly improve patient outcomes by reducing errors, enhancing compliance, and lowering hospital readmission rates. The review highlights key strategies, challenges, and innovations that enhance pharmacist-led adherence programs.

Keywords: drug-induced photosensitivity, photoallergic, phototoxic, adverse drug reactions, medications

Full Text

Introduction

Lack of medication adherence is a patient care issue affecting health systems all over the world [1]. According to WHO estimates, rates of medication non-adherence fall between 30%-50% in patients suffering from chronic illnesses. [2–3] This case is highly common in outpatient clinics where patients are expected to self-administer medication without the constant supervision of a healthcare professional. [3–4] Some of the barriers that enhance non-adherence include misunderstanding of prescribed medication, patient apathy, cognitive and physical limitations, and socioeconomic hurdles. [4–5]

As medication specialists, pharmacists can contribute to better patient outcomes by proactively addressing these issues and offering more elaborate counselling and medication reconciliation services. “Medication reconciliation ensures that patients are not taking medications that may work against each other; otherwise, they will do more harm than good,” Dr. Susan Brown, one of the leading pharmacists of outpatient programs for improving medication adherence, says. [5–6]  These advanced interventions, together with counselling, can significantly increase adherence rates and decrease the risk for repeated admissions.

Recent studies highlight the positive outcomes of pharmacist-led counselling and reconciliation. In one systematic review, pharmacist interventions led to improved adherence rates and reduced medication errors across various outpatient settings. [7] “A pharmacist’s role is more than just dispensing medications. It’s about ensuring the right patient gets the right medication at the right time,” emphasizes Kwan et al. (2019). See Table-1 for an overview of key counselling components. [8]

Material and Methods 

This review included peer-reviewed articles from databases such as PubMed, Scopus, and Google Scholar, published between 2015 and 2025. Studies focusing on pharmacist-led medication reconciliation, counselling interventions, post-discharge counselling, and their impact on outpatient adherence were considered. Keywords used included “medication counselling,” “pharmacist interventions,” “medication adherence,” “outpatient settings,” and “medication reconciliation.” Articles were screened for relevance, and data were extracted for qualitative synthesis.

Findings and Discussion 

  1. Role of Pharmacist-Led Medication Counselling:

Counselling done by pharmacists has enhanced medication adherence greatly by increasing patient education, resolving issues, and motivating patients. Patients should be empathically and extensively educated about the purpose, dosage, and possible side effects of medications. [7, 8] Education provided by pharmacists increased adherence by 20% for patients suffering from hypertension. [8] “Patients are more empowered and controllable over their health needs when they understand the reasoning behind the medications they take,” explain Lee et al. Adherence can be fostered through the use of motivational interviewing and other behavioural cognitive approaches. [9, 10] These tactics help patients who have psychological obstacles and raise their willingness to comply with medication orders. Providing patients with ongoing counselling helps to address new and old problems that patients need to be concerned about in order to reinforce adherence. [11] These follow-ups help in identifying non adherence early enough and providing suitable solutions. Refer to Table-1 for a summary of major counselling components. [10, 11]

Table-1 Key Components of Pharmacist-Led counselling [1, 8]

Key Component

Descriptions
Patient Education Explaining medication purpose, dosage, and side effects to patients clearly
Behavioural counselling Using motivational techniques to enhance patient adherence
Follow-Up and Monitoring Regularly checking on patients to ensure adherence and address concerns
  1. Medication Reconciliation as a Tool for Adherence

Medication reconciliation ensures that the patients have an accurate and up to date medication list. This step is especially important during transitions in care such as from a hospitalization to an outpatient follow up.

Pharmacists are crucial in: Causative Medication Errors- The process of finding out medication discrepancy and resolving them for safety purposes. [5, 6] Missing medications, Prescribed medications with wrong dosage, Prescribed medicines with wrong dosage, and Prescribed medicines with duplicate Though these vary between different healthcare practices, most practitioners experience them. Look at Table-2 for examples of medication discrepancies that are most likely to be encountered. Causative Medication Errors- Detecting the corrective changes in an extensive description and altering them whether or not needed. [12, 13] This is especially helpful in compliance issues for older people or patients who take more than one prescribed medicine. Coordinative care: Working together with the physician and other medical personnel to refine treatment. [14, 15] In a collaborative health care model, every member of the health care team is apprised of the patient’s medication and can make decisions.

Table-2  Common Discrepancies Identified During Medication Reconciliation [5, 7]

Discrepancy Type

Descriptions
Omitted Medications Medications that were not prescribed or taken as intended
Incorrect Dosages Dosages that differ from prescribed amounts
Duplicate Medications Patients taking two or more medications with the same active ingredient
Drug-Drug Interactions Medications that negatively interact with each other
  1. Patient Reconciliation Counselling for Post-Inpatients

Pharmacists’ involvement in medication reconciliation after hospital discharge is critical for ensuring continuity of care. Many patients experience medication changes during hospitalization, which can lead to confusion and non-adherence after discharge. Pharmacists can play a crucial role in bridging this transition by: 1. Providing detailed medication counselling before hospital discharge, including explanations of new medications, dosage changes, and potential side effects. [15] 2. Conducting follow-up calls or visits within 48 hours of discharge to address any medication-related questions or concerns. [15, 16] 3. Ensuring that primary care providers are informed of any medication changes made during hospitalization. [17, 18]

Studies have shown that post-discharge medication counselling significantly reduces hospital readmissions and improves adherence rates. For example, a randomized controlled trial found that patients who received post-discharge counselling from pharmacists had a 25% lower risk of readmission within 30 days. [7, 8]

  1. Combined Counselling and Reconciliation Interventions

Several studies have highlighted the synergistic effect of combining medication reconciliation with tailored counselling. Such integrated approaches have shown reductions in medication errors, improved clinical outcomes, and higher patient satisfaction. Interventions that include both components are more likely to sustain long-term adherence. [19, 20] In a randomized controlled trial, patients who received both counselling and reconciliation had a 30% higher adherence rate compared to those who received standard care.  [20, 21] This dual approach also led to a significant reduction in hospital readmissions and emergency department visits.

  1. Barriers and Challenges

Despite the benefits, barriers to pharmacist-led interventions persist. Common challenges include: 1. Limited pharmacist availability in busy outpatient settings. [21, 22] Pharmacists often have competing responsibilities, making it difficult to allocate sufficient time for counselling. 2. Cognitive decline, health literacy, and socioeconomic factors that affect adherence. [22, 23] Patients with low health literacy may struggle to understand medication instructions, while financial constraints can prevent access to necessary medications. 3. Lack of reimbursement for counselling services and limited integration with primary care teams. [24] Addressing these systemic barriers is essential for scaling pharmacist-led interventions. Refer to Table-3 for a summary of barriers to effective pharmacist interventions. [23, 24]

Table-3 Barriers to Effective Pharmacist-Led Counselling and Reconciliation [9, 10]

Barrier

Description
Time Constraints Limited pharmacist availability in busy settings
Patient Health Literacy Difficulty understanding medication instructions due to low health literacy
Socioeconomic Barriers Financial constraints that limit medication access
System-Level Issues Lack of reimbursement and integration with healthcare teams

 6.  Technological Innovations to Enhance Pharmacist Led Counselling

Digital health technologies, such as mobile applications, telehealth, and electronic medication management systems, have the potential to augment pharmacist interventions. These tools can facilitate remote counselling, medication reminders,  and  real-time adherence monitoring. [8, 9] Telehealth platforms enable pharmacists to provide virtual counselling sessions, increasing access for patients in remote or underserved areas. Additionally, mobile applications can send automated reminders and educational materials to patients, further promoting adherence. [10]

Conclusion

Pharmacist-led medication counselling and reconciliation are essential strategies for improving outpatient medication adherence. By addressing barriers, employing tailored interventions, and leveraging technological innovations, pharmacists can play a pivotal role in optimizing patient outcomes. Future research should focus on large-scale implementation and evaluation of these interventions to further substantiate their effectiveness.

Recommendations

To optimize the impact of pharmacist-led medication counselling and reconciliation, the following strategies are recommended:

  1. Policy and System Changes: Advocate for policies that support pharmacist reimbursement and integration into multidisciplinary teams. Enhanced reimbursement models could incentivize pharmacists to dedicate more time to counselling.
  2. Training and Development: Enhance pharmacists’ skills in patient-centred communication and behavioural counselling.. Continuous education programs can ensure pharmacists are equipped with the latest evidence-based strategies.
  3. Technology Integration: Leverage digital health solutions to improve counselling efficiency and adherence tracking.

Conflict of Interest – None

Source of funding – None

Authors’ Contributions

NN: Wrote the manuscript, PK and CD: Contributed equally in editing and reviewing this review article.  NN, PK and CD:  All were red the article and accepted to publish.

NN – Nisha Newar, PK – Preeti Kumari, CD – Chitamala Das

Nisha Newar:  https://orcid.org/0009-0005-7877-4588

References

  1. Basheti IA, Armour CL, Reddel HK, & Bosnic-Anticevich, SZ. Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists.  Journal of Clinical Pharmacy and Therapeutics 2020;45(2):346-352.  PMID: 17433831  DOI: https://doi.org/10.1016/j.jaci.2007.02.037
  2. Brown MT, & Bussell JK. Medication adherence: WHO cares? Mayo Clinic Proceedings 2018;93(3):345-352. PMID: 21389250   PMCID: PMC3068890   DOI: https://doi.org/10.4065/mcp.2010.0575
  3. Costa E, Giardini A, Savin M, Menditto E, Lehane E, Byrne M, & Marengoni A. Interventional tools to improve medication adherence: review of literature. Patient Preference and Adherence 2015;9:1303–1314.  PMID: 26396502    PMCID: PMC4576894    DOI: https://doi.org/10.2147/PPA.S87551
  4. Julius RJ, Novitsky MA Jr, Dubin WR. Medication adherence: a review of the literature and implications for clinical practice. J Psychiatr Pract 2009;15(1):34-44. DOI: https://doi.org/10.1097/01.pra.0000344917.43780.77 PMID:
  5. Kwan, J. L., Lo, L., Sampson, M., & Shojania, K. G. (2019). Medication reconciliation during transitions of care as a patient safety strategy. Annals of Internal Medicine, 158(5_Part_2):397–403.
  6. Vasudevan, S. Menstrual health and hygiene practices of adolescent girls attending school in rural parts of South India and its effect on school attendance in the year 2020: A descriptive cross-sectional study. International Journal of Medical Sciences and Nursing Research 2024;4(3):6-14.  DOI: https://doi.org/10.55349/ijmsnr.202443614
  7. Davis EM, Packard KA, Jackevicius CA. The pharmacist role in predicting and improving medication adherence in heart failure patients. J Manag Care Spec Pharm. 2014;20(7):741-55. DOI: https://doi.org/10.18553/jmcp.2014.20.7.741 PMID: 24967527; PMCID: PMC
  8. Lee GK, Wang HH, Liu KQ, Cheung Y, Morisky DE, Wong MC, et al., Impact of medication adherence on chronic disease management in primary care.  BMC Family Practice 2021;17(1):1–9.
  9. Mekonnen, AB, McLachlan AJ, & Brien JA. Effectiveness of pharmacist-led medication reconciliation programs on clinical outcomes at hospital transitions. Journal of Clinical Pharmacy and Therapeutics 2016;41(6):614-620.
  10. Nieuwlaat R, Wilczynski N, Navarro T, Hobson N, Jeffery R, Keepanasseril A, et al., Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2014.
  11. Shukla A, Ganie MA., Vasudevan S, Gautam R, Bhattacharya P, & Others. Trends of age at onset of menarche among Indian women of reproductive age and its association with the presence of PCOS and related features: A multicentric cross-sectional study. The Journal of Obstetrics and Gynecology of India 2024. DOI: https://doi.org/10.1007/s13224-024-01994-6
  12. Burkhart PV, Sabaté E. Adherence to long-term therapies: evidence for action. J Nurs Scholarsh 2003;35(3):207. PMID: 14562485
  13. Morisky DE, Ang A, & Krousel-Wood M. Predictive validity of a medication adherence measure in an outpatient setting. Journal of Clinical Hypertension 2017;12(5):346-354.
  14. Brinkerhoff, J., & Burroughs, D. (2018). Post-discharge pharmacist-led medication reconciliation and follow-up in a large health system. American Journal of Health-System Pharmacy, 75(12), 676–685
  15. Al-Jumah KA, Qureshi NA. Impact of pharmacist interventions on patients’ adherence to antidepressants and patient-reported outcomes: a systematic review. Patient Prefer Adherence. 2012;6:87-100. DOI: https://doi.org/10.2147/PPA.S27436 PMID: 22346345; PMCID: PMC
  16. Haynes RB, Yao X, Degani A, Kripalani S, Garg A, McDonald HP. Interventions to enhance medication adherence. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD000011.  DOI: https://doi.org/10.1002/14651858.CD000011.pub2   PMID:
  17. Vasudevan S, Davidson PD, Kandhan LV, Rani RHM., & Others. Development and validation of a screening tool for the identification of refractive errors among school-going children in Tamil Nadu, India. National Journal of Community Medicine 2023;14(09):581-587. DOI: https://doi.org/10.55489/njcm.140920232751
  18. McKee M, Frei BL, Garcia A, Fike D, Soefje SA. Impact of clinical pharmacy services on patients in an outpatient chemotherapy academic clinic. J Oncol Pharm Pract 2011;17(4):387-94. DOI: https://doi.org/10.1177/1078155210389217 PMID:
  19. Ponniah A, Anderson B, Shakib S, Doecke CJ, Angley M. Pharmacists’ role in the post-discharge management of patients with heart failure: a literature review. J Clin Pharm Ther 2007;32(4):343-52. DOI: https://doi.org/10.1111/j.1365-2710.2007.00827.x   PMID:
  20. Zahra Ebrahimi, Harshida Patel, Helle Wijk, Inger Ekman, Patricia Olaya-Contreras, A systematic review on implementation of person-centered care interventions for older people in out-of-hospital settings, Geriatric Nursing 2021;42(1):213-224, DOI: https://doi.org/10.1016/j.gerinurse.2020.08.004
  21. Vasudevan, S., Singh, S., Newar, N., AB, A., & Others. A perception on COVID-19 vaccinations among tribal communities in East Khasi Hills in Meghalaya. International Journal of Medical Sciences and Nursing Research 2022;2(1):5-9. DOI: https://doi.org/10.55349/ijmsnr.20222159
  22. Chumney EC, Robinson LC. The effects of pharmacist interventions on patients with polypharmacy. Pharm Pract (Granada) 2006;4(3):103-109. MID: 25247007; PMCID: PMC
  23. Krousel-Wood M, Craig LS, Peacock E, Zlotnick E, O’Connell S, Bradford D, Shi L, Petty R. Medication Adherence: Expanding the Conceptual Framework. Am J Hypertens 2021;34(9):895-909. DOI: https://doi.org/10.1093/ajh/hpab046 PMID: 33693474; PMCID: PMC
  24. Marcum ZA, Jiang S, Bacci JL, Ruppar TM. Pharmacist-led interventions to improve medication adherence in older adults: A meta-analysis. J Am Geriatr Soc 2021;69(11):3301-3311. DOI: https://doi.org/10.1111/jgs.17373  PMID: 34287846

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑Non-Commercial‑ShareAlike 4.0 International License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given, and the new creations are licensed under the identical terms.

Abstract      Full-Text PDF