Pharmacists Strengthen Transitions of Care to Improve Patient Outcomes

Transitional care is the treatment and logistics involved when a patient leaves one care setting and enters another. This can be within settings (eg, between wards in the same hospital), between settings (eg, one hospital to another), across health states (eg, patient residence to assisted living), or between providers (eg, acute care provider to specialist). The actions taken during this time are designed to ensure coordination, continuity, and support for a comprehensive care plan, and they should be undertaken by well-trained practitioners informed about the patient’s treatment goals, preferences, and health status.¹

Medication errors have been attributed to poor communication and loss of important information during a transition of care. These errors may result in clinically relevant outcomes, including adverse drug reactions, increased duration of hospital stay, early hospital readmission, and unnecessary use of other health care resources.

Pharmacists play an important role in transitions of care by ensuring medication safety and effectiveness during patient movement between care settings. Pharmacist involvement helps prevent medication errors, optimize patient outcomes, and reduce readmission rates to the hospital.²

Key Roles

Pharmacist participation in transitions of care can provide patients with individualized interventions to address medication management challenges in many ways. Key aspects include medication reconciliation, patient and caregiver education, discharge planning, and ongoing follow-up and communication.

Medication reconciliation is the process of comparing the medications a patient currently takes with medications ordered at each transition. Proper medication reconciliation includes a thorough account of all current medications, including prescription and nonprescription medications, as well as supplements. This information should be cross-referenced for verification, and any discrepancies should be identified and resolved. Reconciled medications should be documented and shared with all relevant providers and the patient.³

As medication experts, pharmacists are well equipped to educate patients and caregivers on medications. Relevant information should include dosage, administration, potential adverse effects, and possible drug interactions.

Pharmacist input in discharge planning typically includes optimizing discharge medications through patient and caregiver education. Pharmacists may also help patients find affordable medications. Postdischarge pharmacist follow-up is crucial to address medication issues, such as adherence issues, misunderstandings, and the minimization of adverse effects.

Successful transitions of care require communication and collaboration. This includes clear and honest communication among all parties, including patients, caregivers, and health care professionals.⁴

Barriers During Transitions of Care

Several barriers can interfere with pharmacists’ full participation in and impact on transitions of care. During transitions of care, pharmacists may have communication difficulties with providers or patients, including language barriers, cultural ambiguities, lack of access to patient information, inadequate documentation, and/or conflicting recommendations.⁵

Time constraints are a barrier to pharmacist-led transitions of care because care settings with a high turnover rate require pharmacists to manage many transitions within a short period. Patients with comorbidities and complex medication regimens require more time for counseling and education. Additionally, pharmacists specializing in transitions of care require training and education, which is an ongoing process.⁶

Appropriate interprofessional collaboration is vital for patient-centered care, but can be challenging. This requires teamwork, efficient resource utilization, and role clarity for all stakeholders. When patients, caregivers, and health care providers understand their respective roles and responsibilities, transitions become smoother, leading to more positive patient outcomes.⁷

Patient-related factors can have a profound impact on transitions of care. These factors include low health literacy, poor self-management skills, lack of social support, cultural and linguistic differences, and financial/insurance factors. Psychological factors can also affect transitions of care, including stress, anxiety, and fear.⁸ System-level barriers to transitions of care include incomplete information transfer, lack of standardized processes, lack of integration, lack of accountability, limited resources, inadequate technology, and financial disincentives.⁹

Impacts of Pharmacist-Led Transitions of Care

Pharmacist-led transition of care has been shown to be positive and worthwhile. Pharmacists perform accurate medication reconciliation, provide education on new and existing medications, and address potential medication-related problems. In doing so, they improve patient outcomes and reduce hospital readmissions significantly.¹⁰

Pharmacists also help prevent medication errors and adverse drug events and reduce hospital readmissions, thereby enhancing patient safety through pharmacist-led transitions of care. Additionally, the pharmacists’ expertise in medication reconciliation, patient education, and addressing of potential medication-related issues leads to a more positive and confident patient experience.

Finally, the economic burden of hospital readmissions is well established. Medication-related problems cause an estimated 67% of postdischarge adverse events.¹¹ Pharmacist-led transitions of care that incorporate medication reconciliation reduce these medication-related problems, thereby reducing hospital readmissions and lowering health care costs.¹¹

Conclusion

Pharmacists are playing an increasingly important role in transitions of care. By focusing on medication reconciliation and patient education and empowerment, pharmacists help reduce medication errors and hospital readmissions, and improve overall patient outcomes and satisfaction with care.

Pharmacists can obtain certification in transitions of care through various programs offered by organizations such as the Texas Society of Health System Pharmacists, the American Pharmacists Association, and the University of Hawaii. These programs provide pharmacists with specialized knowledge and skills to develop, implement, and manage transitions of care programs, addressing challenges and improving patient outcomes during care transitions.

Although many barriers to pharmacist-led transitions of care exist, it is imperative that these barriers are overcome and that pharmacists’ contributions are maximized to ensure patient safety and positive patient outcomes.

REFERENCES

1. Definitions of transitional care. National Association of Clinical Nurse Specialists. Accessed July 30, 2025. https://nacns.org/resources/toolkits-and-reports/transitions-of-care/definitions-of-transitional-care/

2. Kristeller J. Transition of care: pharmacist help needed. Hosp Pharm. 2014;49(3):215-216. doi:10.1310/hpj4903-215

3. Quick Safety Issue 26: transitions of care: managing medications. Joint Commission. Updated April 2022. Accessed July 30, 2025. https://www.jointcommission. org/en-us/knowledge-library/newsletters/quick-safety/issue-26

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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 Col Clin Pharm. 2023;7(1):8-14.doi:10.1002/jac5.1887

7. Satake A, McElroy V. Inpatient transitions of care: challenges and safety practices. Patient Safety Network. March 27, 2024. Accessed July 30, 2025. https://psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices

8. Bailey A, Mallow J, Theeke L. Perceived self-efficacy, confidence, and skill among factors of adult patient participation in transitional care: a systematic review of quantitative studies. SAGE Open Nurs. 2022;8:23779608221074658. doi:10.1177/23779608221074658

9. Corbett CF, Dupler AE, Smith S, Balogh EM, Bolkan CR. Advances in patient safety and medical liability. Agency for Healthcare Research and Quality. August 2017. Accessed July 30, 2025. https://www.ahrq.gov/patient-safety/reports/liability/corbett.html

10. Ni W, Colayco D, Hashimoto J, et al. Impact of a pharmacy-based transitional care program on hospital readmissions. Am J Manag Care. 2017;23(3):170-176.

11. Ni W, Colayco D, Hashimoto J, et al. Budget impact analysis of a pharmacist- provided transition of care program. J Manag Care Spec Pharm.2018;24(2):90-96. doi:10.18553/jmcp.2018.24.2.90