Transition of Care: Pharmacist Help Needed:

Transition of care involves the coordination and continuity of health care as patients transfer between different settings. The transition between inpatient and community settings in particular is prone to medication errors related to a lack of communication between health care providers, missed patient follow-up, inadequate patient education, incomplete medication reconciliation, and the absence of patient involvement in medication management. Inconsistent care coordination contributes to the readmission of 20% of patients within 30 days of discharge.1 Interest in preventing readmissions has grown since the Center for Medicare and Medicaid Services (CMS) has imposed financial penalties on hospitals with high 30-day readmission rates. Pharmacists can and should take a more active role in improving medication safety during care transitions; this could lead to a reduction in hospital readmissions and improved quality of care. Several initiatives have been described to improve the transition of care, many of which involve pharmacists.2,3 Medication reconciliation, medication therapy management, and patient education form the core of pharmacist activities that may improve the care provided during transitions. Unfortunately, many programs are focused on either the inpatient or outpatient settings, with minimal collaboration between hospital and community pharmacists. A longitudinal approach across health care settings is needed to coordinate inpatient and postdischarge care and medication management. Improving medication management during care transitions will require 3 main initiatives. First, the patient must remain the central focus of care. Second, interprofessional communication and collaboration need to occur among all providers involved in the health care of individual patients. Third, the outcomes of pharmacist involvement during care transitions needs to be evaluated systematically (ideally in controlled trials) to demonstrate a cost-effective improvement in quality and to provide financial justification for investing in pharmacist resources. For patients to remain the central focus of care, they need to share in the decision-making process. Patients need to understand and agree with their treatment plan, and their caregivers also need to be involved. Pharmacists should initiate conversations with patients and caregivers to ascertain their understanding, health literacy, beliefs, attitudes, goals, values, and preferences. It has been suggested that medication adherence is a test of the practitioner’s ability to practice in a patient-centered manner.4 Conversely, medication nonadherence likely contributes to hospital readmissions and increased health care spending.5 Quality improvement initiatives are unlikely to succeed if the patient’s perspective has not been taken into consideration, thus patient and caregiver involvement is foundational for improving care transitions. Collaboration between hospital and community pharmacists can also facilitate patient-centered care. Multiple medication changes during hospitalization can be confusing to patients, caregivers, and providers, and can lead to medication errors. Hospital pharmacists can provide a reconciled medication list and meet with patients for counseling and education. Typically, the day of discharge is busy, and patients have limited time and attention to discuss important issues. A “hand-off” or pharmacist discharge care plan could facilitate the coordination of medication management between the hospital and community pharmacist. This provides continuity so that the community pharmacist has a list of actual or potential medication-related problems to follow-up on with the patient or other health care providers. It also provides the community pharmacist with patient information that they would not normally have access to. In addition to collaborating with each other, pharmacists need to work with other health care professionals including physicians, care managers, nurses, and others to provide coordinated care to individual patients. Pharmacists are uniquely positioned and qualified to identify, prevent, and correct medication-related problems, but this is only accomplished through effective communication among health care providers. For example, home health nurses discuss medication-related issues with patients. It is imperative that patients are provided with consistent and accurate information, which necessitates communication between the pharmacist and home health nurse. Busy work schedules are often a barrier to communication, so health care providers need to be proactive in determining the best methods to stay connected with each other. When communicating with prescribers, consideration should be given to how office-based nurses or care managers can facilitate the process. Pharmacist involvement in care transitions can be costly, and administrators will need justification for the added resources. Limited resources may explain why less than 12% of hospitals enrolled in the “hospital to home” quality campaign have pharmacist involvement in discharge medication reconciliation on a regular basis.6 More evidence is needed to determine whether strategies to coordinate care during transitions improve outcomes. Although several quality improvement initiatives have been proposed, few controlled trials have demonstrated a reduction in readmissions. There is, however, evidence that strategies involving inpatient nurse discharge advocates,7 case managers,8 and nurse home visits9 can reduce readmissions. Interprofessional collaboration involving hospital and community pharmacists could improve outcomes further by incorporating the pharmacist’s expertise in medication management. Before implementing resource-intensive programs, we need evidence that pharmacist involvement in these programs improves outcomes and is cost-effective. Resources should be targeted toward patient populations at increased risk for readmission, such as patients with heart failure, chronic obstructive pulmonary disease, asthma, advanced age, low health literacy, and frequent hospitalizations. In summary, hospital and community pharmacists need to work together and partner with other health care professionals to provide patient-centered care and coordinated medication management that is integrated throughout care transitions. Evidence is then needed to quantify the added value and improvement in quality. Demonstration of a cost-effective improvement in outcomes provides justification for reimbursement of the care provided by pharmacists. Pharmacists are experts at medication management and error prevention, a primary focus during care transitions. That expertise is currently underutilized and is greatly needed to improve the quality of care provided during care transitions.