Pharmacists Can Help Overcome Challenges in Care Transitions

JANUARY 04, 2017
Sharnetria Wright,  PharmD Candidate 2017, Harrison School of Pharmacy Auburn Univeristy and Daryl-Kristine Vasquez, PharmD Candidate, 2017 Harrison School of Pharmacy Auburn Univeristy also contributed to this article. 

Transition of care is defined by the National Transitions of Care Coalition as “the movement of patients between health care locations, providers, or different levels of care within the same location as their conditions or care needs change.”1 Care transitions occur within health care systems, such as from the intensive care unit (ICU) to the general medical ward, between health care systems, or to home.

The provision of quality transitions of care has been a focus of Medicare. Approximately 20% of Medicare patients discharged from the hospital are readmitted within 30 days.2 Prior to the 2010 Affordable Care Act (ACA), Medicare was spending up to $17 billion as a consequence of high readmissions rates.3 The ACA established the Hospital Readmissions Reduction Program, which reduces the Centers for Medicare & Medicaid Services (CMS) payments to hospitals with high readmission rates.4 In the transition of care, medication discrepancies with respect to name, dose, route, or frequency increase adverse drug events and account for many of these hospital readmissions. It was estimated that more than 1 million Americans were hospitalized because of adverse drug events in 1994, which accounted for approximately 4.7% of all admissions.5 Because of this, pharmacists in the hospital and community settings have expanding roles in the transition of care.

Decreasing Hospital Readmission Rates: Hospital Pharmacists

Hospital pharmacists have several opportunities to facilitate the transition of care of patients. The Joint Commission requires medication reconciliation at every hospital admission; with pharmacists being drug experts, they are ideal for the task.1 Their goal is to reduce negative patient outcomes from medication-related errors. 

Effective medication reconciliation includes how and when the patient takes their medications, dosages, indications, prescribers, and missed doses.6 A 2002 study Nester et al supports pharmacists’ role in medication reconciliation. 7It compared pharmacist-obtained medication histories to nurse-obtained medication histories and found that significantly more patients had clinical interventions when a pharmacist conducted medication reconciliation (34% vs. 16%;p <0.001).  Pharmacists were also able to identify more patients taking OTC products and herbal supplements (98% vs 70%;P<0.001).7

Pharmacists can perform medication reconciliations and interviews at discharge to prepare patients for new medications and discontinuation, resumption, or alteration of home regimens.  This includes ensuring that a follow-up plan is in place for medication monitoring. 

Currently many of the responsibilities of medication management post-discharge fall to outpatient providers, but either an inpatient or outpatient pharmacist could participate as part of a broader transitions of care team. Ideally, according to studies, a telephone follow-up should occur two to four days after discharge.8 This coincides with Medicare’s Transitional Care Management Services in which they pay for beneficiaries to receive face-to-face visits and non-face-to-face contact in the 30 days of a the patient being discharged from certain facilities to community settings.9 

One randomized study in 178 discharged patients evaluated pharmacist-performed discharge counseling and telephone follow-up compared with no pharmacist intervention.  This study found that the rate of preventable adverse events was significantly lower in the pharmacist intervention group (1% vs. 11%;P =.01).  Furthermore, the rate of medication-related emergency department visits or hospital readmissions was also lower (1% vs. 8%; P =.03).10

Pharmacist participation on rounds has also shown to have a positive impact on readmissions.  Studies have shown that multidisciplinary teams including pharmacists decrease the rates of readmissions, emergency department visits, and adverse drug events.1 Pharmacist participation in rounds allows for the evaluation of drug therapy appropriateness and the anticipation and resolution of problems throughout transitions.8 This is particularly helpful as a patient is transferred between units and/or care services during the hospital stay. Kucukarslan et al. compared outcomes of patients admitted to a general medicine unit who received care from rounding teams with and without pharmacists and found that preventable adverse events were decreased by 78% when pharmacists were part of the team.11

Decreasing Hospital Readmissions: Community Pharmacists

Patient interactions with healthcare professionals decrease when patients are discharged from the hospital. Many patients are unprepared to navigate the self-management role after hospital discharge.  Consequently, patients become vulnerable to medication-related adverse events.  It is estimated that almost 20% of patients discharged from the hospital experience adverse events with medications accounting for approximately two-thirds of these adverse events.12 Of these drug-related adverse events, over half may be preventable. Preventable medication adverse events post discharge may stem from inappropriate medication prescribing, discrepancies between prescribed and actual regimens, inadequate surveillance for adverse drug effects, or poor adherence.10 Because community pharmacists often see patients more frequently than physicians after discharge, they have a potentially important role in decreasing preventable drug-related adverse events and the overall improvement of transitions of care. Key community pharmacist interventions may include the following: medication therapy management (MTM) services, encouragement of patient follow-ups, patient counseling, and prevention of drug-drug, drug-food interactions and medication adherence discrepancies.

In performing these interventions, pharmacists can improve some of the challenges care transitions that lead to medication errors. MTM services after hospital discharge can help to decrease discrepancies in discharge orders and improve chronic disease management. 

In a study by Moore et al, patients receiving MTM services showed a 10.3% reduction in plan-paid health care costs compared to a 0.7% increase in costs in the control group (P=.048). Those patients receiving MTM services also had a significant reduction of 18.6% in inpatient visits compared to a 24.2% increase in hospitalizations in the control (P<.001).13  By increasing patients’ knowledge, medication counseling may increase adherence and prevent drug interactions. Because community pharmacists most commonly dispense new and changed discharge medications to patients after hospitalizations, the results of Moore et al. may be clinically applicable to all retail and community pharmacists as part of a heightened awareness on the importance of the duty to counsel.

Community pharmacy is fast-paced with a heavy day-to-day workload, but pharmacists can maintain time management and still have a major positive impact on care transitions by focusing on high-risk medications and high-risk patient populations. In a systematic review of prospective observational studies, it was found that the most common medications causing adverse drug reactions that necessitated hospitalization in adults included cardiovascular drugs (45.7%), nonsteroidal antiinflammatory drugs (NSAIDs) (14.6%), and central nervous system agents (9.7%).14  Other high-risk patients that would benefit from increased attention include geriatrics, patients with limited health literacy, lower income, and cognitive impairment.8  In a prospective study by Baker et al of 3,260 Medicare managed care enrollees it was found that inadequate functional health literacy had a 52% higher risk of hospital admission.15

Transitions of Care Impact

With the recent focus on quality transitions of care, pharmacists have expanding roles in both inpatient and outpatient settings. Pharmacists’ involvement throughout the process will aid in overcoming transition of care challenges leading to decreased hospital readmissions and improved patient outcomes. 



1.       Sen S, Bowen JF, Ganetsky VS, et al. Pharmacists implementing transitions of care in inpatient, ambulatory and community practice settings [UPDATED]. Pharm Pract. 2014;12(3).

2.       Li J, Young R, Williams MV. Optimizing transitions of care to reduce rehospitalizations. Cleve Clin J Med. 2014;81(5):312.

3.       Zuckerman RB, Sheingold SH, Orav EJ, et al. Readmissions, observation, and the hospital readmissions reduction program. N Engl J Med. 2016;374(16):1543-1551.

4.       Centers for Medicare and Medicaid Services.  Readmission Reduction Program.  Accessed: Nov 30, 2016. Available from:

5.       Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348(16):1556-1564.

6.       Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting Effective Transitions of Care at Hospital Discharge: A Review of Key Issues for Hospitalists. J Hosp Med. 2007;2:314-323.

7.       Nester TM, Hale LS. Effectiveness of a pharmacist-acquired medication history in promoting patient safety. Am J Health-Syst Pharm. 2002; 2221-2225.

8.       Hume AL, Kirwin J, Bieber HL, et al. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012;32(11):e326-37.

9.       Transitional Care Management Services [Internet]. Department of Health and Human Services Centers for Medicare and Medicaid Services. Accessed:  Dec 11, 2016. Available from:

10.   Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166(5):565-571.

11.   Kucukarslan SN, Peters M, Mlynarek M, et al. Pharmacists on Rounding Teams Reduce Preventable Adverse Drug Events in Hospital General Medicine Units. Arch Intern Med. 2003;163(17):2014-2018.

12.   Gil M, Mikaitis DK, Shier G, Johnson TJ, Sims S. Impact of a combined pharmacist and social worker program to reduce hospital readmissions. J of Manag Care Pharm. 2013;19(7):558-563.

13.   Moore JM, Shartle D, Faudskar L, Matlin OS, Brennan TA. Impact of a patient-centered pharmacy program and intervention in a high-risk group. J Manag Care Pharm. 2013;19(3):228-236.

14.   Kongkaew C, Noyce PR, Ashcroft DM. Hospital admissions associated with adverse drug reactions: a systematic review of prospective observational studies. Ann  Pharmacother. 2008;42(7-8):1017-1025.

15.   Baker DW, Gazmararian JA, Williams MV, et al.  Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. Am  J Public Healt. 2002;92(8):1278-1283.

Marilyn Bulloch, PharmD, BCPS
Marilyn Bulloch, PharmD, BCPS
Marilyn Novell Bulloch, PharmD BCPS, is an Associate Clinical Professor of Pharmacy Practice at the Auburn University School of Pharmacy and an Adjunct Assistant Professor at the University of Alabama School of Medicine College of Community Health Sciences Department of Internal Medicine. She completed a post-graduate pharmacy practice residency at the University of Alabama-Birmingham Hospital and a post-graduate specialty residency in critical care pharmacy at Charleston Area Medical Center in Charleston, West Virginia. Dr. Bulloch also completed a Faculty Scholars Program in geriatrics through the University of Alabama-Birmingham Geriatric Education Center in 2011. She serves on multiple committees and in leadership positions for many local, state, and national pharmacy and interdisciplinary medical organizations.
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