Transitions of Care/Handoffs

TIP: Good Shepherd Health offers a unique service. We do a transitional care program with a local for-profit (hospital). We fill their indigent patients’ discharge meds all at once as a 90-day supply. The hospital has to approve med charges if they exceed $400. We follow up via telephone with the patient at 30, 60, 90 days. The patient gets a 90-day membership with us which means they can get their prescriptions for free or at cost. Eventually we hope to show decreased readmissions… We sell the discharge meds to the hospital at cost as well. This hospital doesn’t have an outpatient pharmacy and we bear the full cash price from the nearest (local chain pharmacy.)

An important service required of pharmacies is assistance in transitions of care (TOC). The National Transitions of Care Coalitiondefines transitions of care (TOC) as “the movement of patients between health care locations, providers, or different levels of care within the same location as their conditions or care needs change”. Patients move to and from hospital or ED to outpatient to clinic or primary care practice to pharmacy (s), labs, homecare agencies, and other providers. Each of these transitions is an opportunity for pertinent information to be missed or misinterpreted by patients and or healthcare providers. Lack of insurance may influence access to healthcare, including medications, and ultimately, the ability to adhere to a new discharge plan. (Development and validation of a transitions-of-care pharmacist tool to predict potentially avoidable 30-day readmissions.)

Charity Pharmacies are in a unique position to provide medications for the uninsured, allowing them to be key members of the TOC team. As with other pharmacies, they can provide medication history, including allergies and adverse reactions, and reconciliation at time of hospital admission or ED visit. Working with hospital providers (inpatient pharmacists, case managers, physicians and other prescribers), the charity pharmacist can help develop a free or affordable medication regimen for the patient, ideally prior to discharge. Check with state board of pharmacy for pharmacist scope of practice. (See Collaborative Practices and Appendices\Collaborative Practice Regulations for additional information. See example forms for referrals and delivery in

Transitions of Care: Case Examples Resource,published by APhA, provides examples of pharmacy personnel roles, successes and barriers from six clinical settings.

ASHP and APhA collaborated to provide a TOC best practice report,ASHP-APhA Medication Management in Care Transitions Best Practices.Each of eight best practice cases presents processes, barriers, cost justification and metrics for their various locations. Mission Hospitals discuss their safe transitions for an uninsured population. Their MissionUninsuredSafe Transitions (MUST) program includes referral at discharge from hospital and followup from pharmacy personnel. A sample technician phone call script is included in the article (ibid pg. 32).

SeeMedication Management in Care Transitions Best Practice,

University of Pittsburgh School of Pharmacy and University of Pittsburgh Medical Center (UPMC) prepared a follow-up checklist for outpatient pharmacists: (ibid, pg. 43) The outpatient care transitions follow-up activities of the pharmacist include:

  • Reviewing the patient’s discharge medication list and home medications.
  • Identifying and resolving any medication discrepancies.
  • Communicating any medication-related changes to the appropriate outpatient pharmacist.
  • Identifying and resolving any ongoing medication-related problems.
  • Contacting other health care professionals, where appropriate, to convey and resolve any issues identified during the post-discharge follow-up call.
  • Updating the patient’s outpatient home medication list in the outpatient EHR.
  • Sending a follow-up note to the patient’s primary care physician.