Pharmacists Are Vital to Transitions of Care

Pharmacy TimesApril 2023
Volume 89
Issue 4

Clinical interventions, follow-ups, medication reconciliation, patient education are key aspects of the programs.

Transitions of care (TOC) involves patients moving from one health care provider or setting to a different one, which can increase the risk of adverse events related to communication about issues such as discharge medications.1

Approximately 1 in 5 patients receiving Medicare who are discharged from the hospital are readmitted within 30 days.1 Pharmacists can play a key role in TOC to improve patient health outcomes (Figure1-5).

In 2015, the Memphis Veterans Affairs Medical Center in Tennessee implemented a transitional care clinic (TCC) led by a clinical pharmacy specialist (CPS).2 The CPS provided follow-up care to patients discharged from emergency departments and hospitals. A retrospective review of the TCC found that the readmission rate for patients with chronic obstructive pulmonary disease (COPD) was 13%.2 Additionally, the readmission rate for patients with heart failure (HF) was 10% for the TCC program.2 The hospitalwide readmission rates for COPD and HF were 19% and 24%, respectively.2 This demonstrates the value that a CPS adds to TOC programs.

Errors can occur during TOC for many reasons. Communication breakdowns among health care providers, a lack of patient education, and medication reconciliation errors are a few examples.3 Medication therapy management (MTM) can help improve patient outcomes involving TOC.3 Because documentation of medication lists is a key component of MTM, pharmacists are well positioned to incorporate this into TOC.

The Joint Commission recommends involving pharmacists in the medication reconciliation process, because they play a major role on interdisciplinary teams conducting clinical interventions.4 All care settings should establish MTM in their policies and processes, according to The Joint Commission. Pharmacists can play a key role in evaluating risks that may impede medication access at the receiving facility.4 Referring patients for home health care services after they are discharged from the hospital with new medications can assist with the adjustment.4 Additionally, this may improve adherence and prevent medication errors. Pharmacists can ensure that patients will have access to their medications at assisted-living or skilled-nursing facilities by determining the pharmacy formulary at the setting.4 Caregiver and patient education at discharge is also critical. Medications should be clearly written in the discharge summary or transition plan.4

One study evaluated the impact of a TOC pharmacist on hospital re-presentation rates for adult patients after discharge.5 The TOC pharmacist performed a variety of clinical roles for the study that included the following5:

  • Communicated with the next level of care
  • Conducted patient discharge education
  • Consulted with the patient or caregiver to determine barriers
  • Reviewed the admission reconciliation and medication history
  • Reviewed discharge reconciliation

The primary outcome was a 30-day re-presentation rate.5 There were 384 patients who met the study inclusion criteria, and data were compared with 1221 control patients.5 The study results showed that the TOC pharmacist intervention had an 11% absolute and 50.2% relative reduction in 30-day representation rates.5 The study estimated that for every $1 invested in pharmacist time, $12 was saved.5 Additionally, the TOC pharmacist made 904 interventions during the study period.5 This demonstrates that a TOC pharmacist plays a key role in preventing hospital re-presentations and can save money for facilities.


1. Community-based care transitions program. Centers for Medicare & Medicaid Services. Updated March 24, 2022. Accessed February 9, 2023.

2. Clinical pharmacy specialists provide transitional care and improve medication safety after discharge at Memphis Veterans Affairs Medical Center. Agency for Healthcare Research and Quality. May 16, 2022. Accessed February 13, 2023.

3. Chapter 3: Transition of care, MTM, and ambulatory care. The Medication Therapy Management Pharmacist Reference Book. 1st Ed. The National Board of Medication Therapy Management. Accessed February 12, 2023.

4. Quick safety issue 26: transitions of care: managing medications. The Joint Commission. Updated April 2022. Accessed February 12, 2023.

5. Rafferty A, Denslow S, Michalets EL. Pharmacist-provided medication management in interdisciplinary transitions in a community hospital (PMIT). Ann Pharmacother. 2016;50(8):649-655. doi:10.1177/1060028016653139

About the Author

Jennifer Gershman, PharmD, CPh, PACS, is a drug information pharmacist and Pharmacy Times® contributor who lives in South Florida.

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