By: Sami Barakat, PharmD. and Natalia Jucha, PharmD. Candidate c/o 2022
Since the publication of the Institute of Medicine report To Err is Human: Building a Safer Health System, there has been a growing movement to improve patient safety. The report revealed that more than 7000 deaths occur annually due to medication errors.1 It is estimated that 60% of medication errors occur during a patient’s transition between healthcare settings.2 As a result, there has been a growing focus on improving outcomes during the transition phase. Although safety is a big concern in practice, we cannot overlook the rising cost of healthcare and how errors contribute to that cost. It is estimated that medication errors cost our healthcare system 21 billion dollars every year.3 Many of these errors lead to adverse drug events and re-hospitalization. It is therefore no surprise that healthcare systems, providers, and quality regulators have centered their efforts around optimizing transition of care (TOC).
Transition of care is the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another. While an effective transition of care can lead to reduced hospital readmission, healthcare costs, and adverse events, several barriers negatively impact the quality of the transition. Inadequate discharge counseling and medication education can lead to lack of patient and family engagement. In addition, involvement of multiple specialists can lead to polypharmacy, medication errors, lack of accountability, and poor follow-up after discharge. Pharmacists have the education and expertise to address these barriers, collaborate with a multidisciplinary team, and provide a successful transition of care.4 Moreover, quality regulators such as the Joint Commission recognize the pharmacist’s role within interdisciplinary teams and recommend that all care settings should involve a pharmacist when possible in medication reconciliation.5
Health care organizations developed several TOC models with varying degrees of pharmacy team involvement. Some examples include Project RED (Re-Engineered Discharge) and Medication Management in Care Transitions Model (MMCT). Activities can range from performing medication reconciliation on admission to conducting discharge counseling and following up with the patient after discharge. By doing so, pharmacists act as the bridge between the patient, their providers, and their pharmacy to fill the gap that exists during their transition.
To test Project RED, researchers from Boston Medical Center randomized eligible hospitalized patients to receive RED intervention or usual care. Interventions included patient-centered education, comprehensive discharge planning, and post discharge reinforcement. A clinical pharmacist made telephone follow-ups to reinforce discharge plans, review medications, and solve problems. Patients in the intervention group had lower rates of hospital utilization (ER visits and readmission) within 30 days after discharge (116 vs. 166, p-value 0.009). In addition, the intervention group had a higher rate of PCP follow-up (190 vs 135, p-value <0.001). This study reinforced the utility of the pharmacist as part of the transition of care team.6
As the practice of pharmacy continues to grow and evolve, more institutions are implementing pharmacist-led TOC models. The University of Pittsburgh Medical Center executed a MMCT pilot to address issues in their existing TOC process. In the study, the pharmacists had a myriad of responsibilities: performing medication reconciliation on admission, resolving medication-related problems during hospital stay, conducting discharge counseling, communicating with the outpatient physician, facilitating medication delivery from the outpatient pharmacy, and following-up with the patient after discharge. As a result of implementing a MMCT pilot, pharmacists identified 774 medication discrepancies (mean 3.6 ± 3.4 per patient) and reduced readmission rate from 23.7% to 10.5%. Furthermore, pharmacists helped resolve medication adherence issues in 16% of the patients and access insurance issues in 24% of patients. Thus, this pilot further substantiates the importance of a TOC pharmacist in the inpatient setting.7
As patients move across the care continuum, their healthcare costs increase significantly. To test the impact of TOC pharmacists on cost savings, Synergy Pharmacy Solutions implemented a pharmacist-provided TOC services for patients enrolled in Kern Health Systems (KHS) managed Medicaid health plan. The pharmacist contacted recently discharged patients, who were at high risk of readmission, to perform medication reconciliation, conduct comprehensive medication management, and communicate with providers to address medication-related problems. Before the intervention, the average six-month total health care cost was $8,383 per patient. After factoring the TOC services cost of $99 per patient referred, the net cost savings after the intervention was $2,139. This resulted in cost avoidance of $4.3 million to the KHS plan. This study illustrates the role of the TOC pharmacist in the managed care and outpatient settings.8
As seen with the different TOC models, pharmacists need expertise in the inpatient, ambulatory, and community pharmacy settings as they practice in different patient care areas. While not every TOC pharmacist completes residency training, it is highly encouraged due to the growing demand of the specialty and the knowledge needed to perform inpatient and outpatient patient care functions. Many PGY-1 programs incorporate rotations in transition of care within their curriculum. In addition, there are PGY-2 programs in transition of care and ambulatory care programs with a focus on transition of care.
The plethora of evidence presented in this article supports the role of TOC pharmacists in every practice setting. However, some barriers still exist in implementing pharmacist-led TOC services including, limited financial resources, limited staffing resources, and limited front-line staff buy-in. With the availability of non-profit organizations and federal grants, funding can be secured. Moreover, leveraging the talent of pharmacy students and pharmacy residents to assist in carrying out certain functions of the program, can help provide additional support staff. Lastly, providing data and evidence on the program’s impact on patient care can help gain support from institution leadership and staff.7
In conclusion, becoming a TOC pharmacist can be exceptionally rewarding. The ability to use pharmacotherapy knowledge to provide pharmaceutical care, as well as being able to provide comprehensive patient education provides a unique, intellectually-stimulating career that can be found in transition of care.
- Havens DH, Boroughs L. “To err is human”: a report from the institute of medicine. J Pediatr Health Care. 2000;14(2):77-80. doi:10.1067/mph.2000.105383
- Johnson A, Guirguis E, Grace Y. Preventing medication errors in transitions of care: A patient case approach. Pharm Today. 2015;21(3):79-90. doi:10.1016/S1042-0991(15)30478-3
- Preventing Medication Errors: A $21 Billion Opportunity. Network for Excellend in Health Innovation; 2011:1-2. https://www.nehi.net/bendthecurve/sup/documents/Medication_Errors_%20Brief.pdf
- Transitions of Care: The Need for a More Effective Approach to Continuing Patient Care. The Joint Commission; 2012:1-8. https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-library/hot_topics_transitions_of_carepdf.pdf?db=web&hash=CEFB254D5EC36E4FFE30ABB20A5550E0
- Transitions of Care Managing medications. Accessed November 6, 2020. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/Newsletters/quick-safety/quick-safety-issue-26-transitions-of-care-managing-medications/transitions-of-care-managing-medications
- Jack BW. A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial. Ann Intern Med. 2009;150(3):178. doi:10.7326/0003-4819-150-3-200902030-00007
- Cassano A, Reilly C, Ingram J, et al. ASHP-APhA Medication Management in Care Transitions Best Practices. APhA & ASHP; 2013. https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/quality-improvement/learn-about-quality-improvement-medication-management-care-transitions.ashx
- 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