Pharmacists Bridge the Gaps in Care Transitions

Transitions of care, or the movement of patients between health care settings or providers, impose a significant cost on the health care system due to frequent adverse events and hospital readmissions.¹ These transitions can lead to discrepancies that put patients at risk for adverse drug events, such as therapy duplication, drug-drug interactions, or misunderstandings of dosing regimens.² Although various programs aim to mitigate these risks, pharmacist-driven initiatives have proven particularly effective.

Pharmacists play a crucial role across multiple practice settings in reducing the risks associated with transitions of care. Study findings published in the Journal of the American College of Clinical Pharmacy found that “pharmacist involvement in transitions of care improves patient outcomes and reduces readmission rates.”³

Pharmacists are involved in several critical steps of a patient’s journey, providing numerous opportunities to assist with transitions between care settings. Their presence in hospitals, physicians’ offices, clinics, and community pharmacies positions them well to address care gaps related to transitions.

Transitions of care in and out of inpatient settings are the most obvious and impactful and can be associated with adverse patient outcomes.⁴ When patients enter an inpatient setting, medication reconciliation must be completed to ensure the inpatient provider team can confidently continue, add, or manage the medication regimen and disease states during the patient’s stay. This often requires outreach to the patient’s local pharmacy and multiple providers to verify the patient’s current medications. Hospitals utilize pharmacists and technicians to conduct this research and reconcile patients’ medications.⁵ Additionally, hospital pharmacists manage medications during the hospital stay and work with patients before discharge to facilitate the transition out of the hospital setting.

Discharge counseling is another critical component of transitions of care. Patients who leave the hospital often have new medications or changes to their existing regimen. Pharmacists frequently conduct discharge counseling, explaining medication changes and introducing new medications.⁶ They cover potential adverse effects, medication interactions, food interactions, and dosing regimens to ensure patient adherence. Pharmacists also counsel on disease states and their relation to medications, helping patients understand the reasons for new prescriptions. Study findings by the Journal of the American College of Clinical Pharmacy found that pharmacist- driven discharge counseling reduced 30-day readmission rates by 7% compared with the hospital’s standard discharge care.⁶

Most patients leave the hospital with acute or new maintenance medications. Community pharmacists who care for these patients confirm allergies, review prior prescription histories, check for therapy duplications, and identify risks of drug-drug or clinical interactions. They may need to contact the patient’s primary care physician or specialist to ensure full alignment on current medications and doses. Although the transition from hospital to outpatient care involves pharmacy, the impact of community pharmacy on transitions of care between providers is less visible.

Transitions from primary providers to specialists or clinics are another prime example of an opportunity for adverse events due to transitions of care. Community pharmacists significantly impact these transitions through medication reviews at the point of dispensing and during medication therapy management (MTM) encounters. According to the National Board of Medication Therapy Management, “[MTM] can help improve patient outcomes involving transitions of care. Because documentation of medication lists is a key component of MTM, pharmacists are well positioned to incorporate this into transitions of care.”⁷ MTM is crucial for transitions of care, especially if a patient fills medications at multiple pharmacies. Most MTM platforms use health plan adjudication data, allowing pharmacists to see any medication billed through the patient’s insurance, even if it was not filled at their pharmacy.

Pharmacists’ involvement in transitions of care extends beyond medication reconciliation and discharge counseling. They also play a vital role in educating patients about their conditions and the importance of medication adherence. This education can significantly impact patient outcomes, as informed patients are more likely to follow their prescribed treatment plans and avoid complications that could lead to readmissions.

Moreover, pharmacists are instrumental in coordinating care among various health care providers. This coordination is essential for ensuring that all members of a patient’s health care team are aware of the patient’s medication regimen and any changes made. Effective communication between pharmacists and other health care providers can prevent medication errors and ensure patients receive the best care.

Pharmacist-driven programs are highly effective in improving patient outcomes during transitions of care. For example, a study comparing medication reconciliation performed by pharmacists vs physicians found that pharmacists were more accurate 22% of the time.⁸ Another study in the Journal of Managed Care & Specialty Pharmacy demonstrated that pharmacist-led MTM programs resulted in better medication adherence and lower health care costs.⁹

In addition to these programs, pharmacists are also involved in various initiatives aimed at improving transitions of care. These initiatives include the development of standardized pre–transitions-of-care models for medication reconciliation, implementing and improving electronic health records to facilitate communication between providers, and using telehealth pharmacy services to provide remote counseling and adherence support to patients.

The impact of pharmacist-driven programs on transitions of care is evident in the numerous studies and statistics that highlight their effectiveness. Most notably, the Centers for Medicare & Medicaid Services has recognized the importance of pharmacist involvement in transitions of care and has included medication reconciliation as a key component of its Hospital Readmissions Reduction Program.¹⁰ This recognition underscores pharmacists’ critical role in improving patient outcomes and reducing health care costs.

Transitions of care represent a critical juncture in the health care continuum, where the risk of adverse events and hospital readmissions is notably high. With their extensive knowledge and presence across various health care settings, pharmacists play a vital role in mitigating these risks. Their involvement in medication reconciliation, discharge counseling, and MTM ensures that patients receive consistent and accurate medication information, reducing the likelihood of errors and improving overall patient outcomes. By leveraging pharmacist-driven programs, health care systems can significantly enhance the quality of care during transitions, leading to better patient health and reduced health care costs.

REFERENCES

1. Community-based Care Transitions Program. Centers for Medicare & Medicaid Services. Accessed July 7, 2025. https://www.cms.gov/priorities/innovation/innovation-models/cctp

2. Medication reconciliation. Patient Safety Network. December 15, 2024. Accessed July 7, 2025. https://psnet.ahrq.gov/primer/medication-reconciliation

3. Nowosielski B. Pharmacists’ expertise can improve patient outcomes in transitions of care. Drug Topics. April 14, 2025. Accessed July 7, 2025. https://www.drugtopics.com/view/pharmacists-expertise-can-improve-patient-outcomes-in-transitions-of-care

4. Marsall M, Hornung T, Bäuerle A, Weigl M. Quality of care transition, patient safety incidents, and patients’ health status: a structural equation model on the complexity of the discharge process. BMC Health Serv Res.2024;24(1):576. doi:10.1186/s12913-024-11047-3

5. American Society of Health-System Pharmacists and American Pharmacists Association. ASHP-APhA Medication Management in Care Transitions Best Practices. February 2013. Accessed July 7, 2025. https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/quality-improvement/learn-about-quality-improvement-medication-management-care-transitions.ashx

6. Tasseff N, Axtell S, Nixon B. Effect of extended pharmacist involvement in discharge transitions of care on hospital readmission rates: prospective, randomized, parallel arm design trial. J Am Coll Clin Pharm. 2024;7(1):8-14.doi:10.1002/jac5.1887

7. Thomas DJ, Tran J, eds. The Medication Therapy Management Pharmacist Reference Book. National Board of Medication Therapy Management; 2020.

8. Burgess LH, Kramer J, Castelein C, et al. Pharmacy-led medication reconciliation program reduces adverse drug events and improves satisfaction in a community hospital. HCA Healthc J Med. 2021;2(6):411-421.doi:10.36518/2689-0216.1295

9. Umeh AU, Chima UE, Agbo CE, et al. Pharmacist-led medication therapy management: impact on healthcare utilization and costs. Am J Pharmacother Pharm Sci. 2025;4:4. doi:10.25259/AJPPS_2025_004

10. Hospital Readmissions Reduction Program. Centers for Medicare & Medicaid Services. Updated September 10, 2024. Accessed July 7, 2025.https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/hospital-readmissions-reduction-program-hrrp