How Pharmacists Can Improve Care Transitions


While effective coordination during a patient's transition from hospital to home can improve outcomes, the process is frequently hindered by poor communication between hospital clinicians and primary care providers.

While effective coordination during a patient’s transition from hospital to home can improve outcomes, the process is frequently hindered by poor communication between hospital clinicians and primary care providers (PCPs).

According to a study published in the April 2015 edition of the Journal of General Internal Medicine, this lack of information sharing during care transitions is not only common, but can also lead to adverse consequences following discharge, including readmission.

To gain insight into steps that can improve care transitions, researchers interviewed 58 clinicians who identified several areas in which communication falters throughout the process.

The participants indicated that PCPs and hospital clinicians are often unware of the issues faced by those outside their practice settings, adding that some PCPs frequently did not know when their patients had been admitted to a hospital. Even when admissions are known across providers, there is often a lack of clarity regarding who is responsible for follow-up care, the clinicians suggested.

In an exclusive interview with Pharmacy Times, Judith Kristeller, PharmD, BCPS, associate professor at the Wilkes University School of Pharmacy, pointed out a number of other communication obstacles, including perceived HIPAA barriers and concerns over interrupting workflow.

Dr. Kristeller also alluded to a tendency among health care professionals to avoid collaborating with those outside their practice settings.

“Many health care professionals work in their own silos,” Dr. Kristeller told Pharmacy Times. “There is a culture of not coming out of that silo to communicate and collaborate with each other.”

According to Dr. Kristeller, pharmacists have an important role to play in improving communication during care transitions. Hospital pharmacists, in particular, should encourage the medical team to be mindful of medication changes, given the brief time they have treated the patient. Then, they should communicate any changes to community pharmacists.

“The pharmacists that are taking care of a patient both in and out of the hospital should communicate with each other, specifically about the education they provide to the patient, so that the other can follow up,” Dr. Kristeller said. “They can communicate about medication changes and the rationale, as well as the reason for the hospitalization, in case it’s related to medication.”

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