Recognizing and Overcoming Barriers in the Transition of Care Setting


A multidisciplinary team of nurse practitioners and pharmacists can work together to address patients at an increased risk for hospital readmission.

Establishing proper follow-up care for patients discharged from a hospital is a complex endeavor complicated by several variables. Inadequate discharge education, access to outpatient providers, and lack of medication coverage are common barriers that can contribute to hospital readmissions.1,2

In recent years, the transitions of care (TOC) setting has become recognized as a necessary and beneficial component for patients at an increased risk for hospital readmission. The transitions clinic at AdventHealth Celebration, known as the AdventHealth Care Clinic (AHCC), has made a tremendous impact by reducing hospital readmission.

This is, in part, due to its comprehensive and collaborative approach to patient care. A study found that patients who visit AHCC after their hospitalization experience a 40% relative risk reduction in readmission.3

At AHCC, a multidisciplinary team of nurse practitioners and pharmacists work together to review each patient’s hospital course. The purpose of AHCC, and most TOC clinics, is to help establish proper follow-up care, review discharge medications for discrepancies, assess opportunities for optimization, and address any existing health concerns for the patient.

A large-scale analysis shows significant benefit in clinics around the country who take a similar approach.4 As implementation of TOC services is growing, both its benefit and shortcomings are becoming discovered.

The very transitional nature of TOC that primes this setting for critical interventions may also contribute to some of its limitations. It is important that we talk about these barriers to bring awareness and direct effort toward breaking them down.

Recognizing & Overcoming Obstacles

Despite the observed success TOC services have on readmission rates and patient satisfaction, this setting does not come without its own impediments. Because of the transitional nature of these clinics, provider-patient relationships, knowledge of patient’s drug accessibility, and ability to follow-up and monitor are all limited. These limitations often impact the scale of intervention practitioners are likely to make.

“I may not recommend initiating a GLP-1 agonist for a type 2 diabetic patient with Medicare and pre-existing gastrointestinal conditions as the patient may face cost concerns and gastrointestinal side effects, which may require timely follow-up,” said Laura Chen, PharmD, BCACP.

Even considering the expected benefit from initiation of guideline-directed drug therapy, issues related to drug coverage and increased health care utilization can hamper the implementation of some interventions. Such barriers can be associated with delays in therapy initiation and adherence gaps which negatively impact patient care.5-7

Sometimes there are workarounds for these issues, however, as described by adult medicine nurse practitioner Tina Wells, ARNP, these strategies take up valuable visit time and have variable success.

A barrier we face in determining coverage of certain medications is that an actual prescription is required to be sent to the pharmacy along with patient’s insurance to verify if the medication is covered and the out-of-pocket cost. This is very time consuming, however, an important step in ensuring we are setting the patient up successfully,” Wells said.

Whenever possible, TOC practitioners should critically evaluate patient’s discharge prescriptions, compare current drug therapy to guideline recommendations, and thoroughly research the patient’s drug plan to assess feasibility of interventions.

Ideally, patient drug insurance information—specifically out-of-pocket costs and prior authorization requirements—are available to TOC practitioners to assist in the optimization of drug therapy. The pharmacist is often the practitioner most qualified to take on these responsibilities with consideration of therapeutic substitutions to comply with a plan’s formulary or proper step therapy to avoid prior authorization delays.

“When reviewing drug formularies, I’m usually able to determine what tier a medication falls under, but patients really just want to know the exact cost, which is not always provided. The prior authorization process often requires a lot of waiting on the phone and delays continuity of care. This may mean patients have to wait days before being placed on a regimen. Patients, not surprisingly, become frustrated with the process and that can impact their willingness to adhere to medications,” said Alexander Le, PharmD, MBA.

Bridging the Gap

Several gears are turning at the same time during hospital discharge and for many patients, this includes crucial changes to outpatient drug therapy. The initiation and education of a new drug therapy is especially important for high-risk populations with chronic disease states for which the therapy has been shown to reduce mortality and readmissions.

Prudently starting a new drug therapy may require frequent outpatient follow up, which can introduce hesitance if access to follow up is in question. In these scenarios, practitioners can still address gaps in therapy and improve patient outcomes through effective documentation and communication.

Although you may not be able to fully optimize a patient's medication regimen in one TOC visit, effective documentation and communication promotes implementation at a future visit. Printed education for patients to bring to future primary care visits in addition to mutually-accessible documented recommendations with supportive rationale can set your patient up for success,” said Raechel Moore, PharmD, BCACP.

TOC practitioners can provide stability and support during labile times of recovery by simply highlighting opportunities for drug therapy optimization or providing recommendations for lifestyle modification. The approach of stabilizing versus optimizing can be advantageous when a clinician’s reach is hindered by the obscurities of follow-up laboratory monitoring and adverse effect management.

By focusing on controlling the acute conditions for which the patient was hospitalized and documenting more long-term optimization opportunities for future implementation by an established provider, TOC practitioners can protect their patients from readmission during the high risk 30-day window.

“I approach each patient encounter with the question, ‘What needs to be done today to ensure a smooth transition for this patient back to their primary care physician?’ This helps me to prioritize tasks and tailor the visit to the patient’s needs, which may include patient education on new or existing medications, creating a personalized medication list or medication administration calendar, and submitting refills for needed medications,” said Kimberly Finley, PharmD, BCACP.

Success Through Collaboration

TOC clinics help patients and hospitals. Through discrepancy resolution, therapy optimization, patient education and efficient communication, pharmacy-driven TOC interventions yield significant reductions in hospital readmission rates.

Even with the obstacles described, practitioners at AHCC use several strategies and resources that have shown to provide high-risk patients a greater chance to stay out of the hospital.4,8

Acknowledgement of intervention barriers is the first step in process improvement and quality assurance. As TOC services continue to evolve and improve, practitioners are encouraged to share their shortcomings and successes so that the experiences of others can be leveraged towards improving patient outcomes.


  1. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-187.
  2. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-1828.
  3. Kim S, Nickerson-Troy J, Morse K. Impact of a pharmacist within a transition clinic on 30-day all-cause hospital readmissions. (2019). AdventHealth Celebration Hospital.
  4. Ridwan E, Hadi H, Wu Y, Tsai P. Effects of Transitional Care on Hospital Readmission and Mortality Rate in Subjects With COPD: A Systematic Review and Meta-Analysis. Respiratory Care September 2019, 64 (9) 1146-1156
  5. Cohen R. Strategies Used by Adults to Reduce Their Prescription Drug Costs. National Center for Health Statistics. (2013).
  6. Balkrishnan R, et al. Predictors of medication adherence and associated health care costs in an older population with type 2 diabetes mellitus: a longitudinal cohort study. Clin Ther. 2003;25(11):2958-2971.
  7. Osterberg L, et al. Adherence to Medication. N Engl J Med 2005; 353:487-497
  8. Ladziak N, Nickerson-Troy J, Morse K, Celaru L, Clements E. Impact of a pharmacist within a transition clinic on 30-day all-cause hospital readmissions. (2019). AdventHealth Celebration Hospital.
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