Darian Daniel, PharmD Candidate

Effective transitions of care (TOC) are essential for high-quality care in all patients with acute or chronic illnesses, but gaps in health care are often found during these transitions, particularly from the inpatient to the outpatient setting.

TOC management refers to the continuation and coordination of patient care from one setting to another, such as from a hospital to the patient’s home. This transition includes changes in health care providers and in patient needs during the course of their illness. TOC aspects that require coordination include patient observation, supervision of prognosis (of acute and chronic illnesses), pharmacological treatment management, lifestyle modification recommendations, and implementation of preventive measures.

At each transition point there is a risk that miscommunication will cause medication errors. Studies have found that as many as 50% of patients recently discharged from the hospital experience some type of medication error.

 This could be due in part to discrepancies in medication, potential adverse drug reactions, and poor health literacy among patients. Approximately 2 of 3 postdischarge adverse events are related to some form of medication error, and 29% of those resulted in an emergency department visit or a hospital admission.

Hospital readmission is an issue that affects all disease states, including myocardial infarction (MI). It has been estimated that almost 25% of MI admissions are of patients who have previously experienced an MI, with an annual estimated readmission cost of $718 million.

In response to these gaps in health care, initiatives have been developed to aid patient transition from different systems, such as the Door-to-Balloon (D2B) program, which improves the time it takes for a patient experiencing an MI to receive the necessary treatment. Ideally, a patient will under- go a balloon angioplasty less than 90 minutes after initial symptom onset. The success of D2B helped pave the way for other quality improvement programs, including Hospital to Home, Surviving MI, and the Patient Navigator Program.

The Mind Your Meds program focuses primarily on the medication reconciliation aspect of TOC. It uses medication-driven metrics to verify that patients and health care providers are both up-to-date on the most recent medication regimen prescribed for said patient.

 Similarly, Patient Navigator Program: Focus MI bridges the gap created during TOC and aims to enhance the care and outcome of patients with acute MI and heart failure while lowering the risk of preventable readmissions.

 Performance and quality measures are used as general guides to determine whether patient care is appropriate. Advanced pharmacy practice experience (APPE) students can use these predetermined performance and quality measures to bridge the gap while caring for post-discharge MI patients.

APPE students can help close the TOC gap during hospital rotations and through their work at transitions of care management (TCM) centers. At the hospital, APPE students have access to patient charts and can review all the interventions performed from admission to discharge. At TCM centers, APPE students can read an overview of the patient’s hospitalization and contact the patient for more details.

In addition to reconciling medications and counseling patients, APPE students who work with acute coronary syndrome patients can use programs like the Patient Navigator Program: Focus MI to assess whether the preferred measures were employed with post-MI patients. They can also document the most commonly missed performance and quality measures based on the interventions implemented to improve overall patient outcomes, avoid reimbursement penalties, and reduce hospital readmission rates.

APPE students can also implement the Drug Adherence Work-up tool, which was developed to guide pharmacists and interns to address nonadherence during medication therapy management visits. According to a prospective cohort study, the most common reasons reported for nonadherence were adverse effects (59.1%) and forgetting to take the medication (54.5%).

Finally, student-driven centers at universities, like the Nova Southeastern University College of Pharmacy Accountable Care Organization Research Network, Services, and Education, are ideal venues to implement quality control and outcome programs. In centers like these, students can collaborate with doctors’ offices, access hospital records, and contact patients to provide medication reconciliation and education.

In addition, APPE students have skills to evaluate the patient’s overall hospital stay and discharge to determine whether the program’s set standards were met. One way to achieve this is by giving students preapproved checklists of hospital-specific metrics that can be used to conduct internal performance and quality assessments.

By further assessing performance and quality metrics, APPE students can have an important impact on the fight to improve health care outcomes for patients via proper TOC management.

 is a fourth-year pharmacy student at the Nova Southeastern University College of Pharmacy. While there, she has also obtained her master’s in bioinformatics and master’s in business administration with a concentration in complex health systems.

 is a fourth-year pharmacy student at the Nova Southeastern University College of Pharmacy and works as a medical assistant at Ankle and Foot Specialists in Miami Lakes.

 is a fourth-year pharmacy student at the Nova Southeastern University College of Pharmacy and has more than 4 years of experience working in the pharmaceutical industry.

 is a fourth-year pharmacy student at Nova Southeastern University and works as a pharmacist intern at Publix Pharmacy.

 is a fourth-year pharmacy student at Nova Southeastern University and works as a pharmacist intern at West Kendall Baptist.

, obtained her doctor of pharmacy degree from the Nova Southeastern University (NSU) College of Pharmacy and is currently practicing as a clinical assistant professor at the NSU College of Pharmacy.

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