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Closing Transitions of Care Gaps: The Critical Role of Pharmacists

Transitions of care have long been an area of concern in addressing the continuity and quality of patient management. The reason: ineffective transitions of care and care transition processes have been linked to multiple human and technical challenges that are manifested as performance problems for healthcare organizations. Among the most common and problematic issues that can occur during transitions of care are medication miscues. Medication errors are a significant and all-too-common problem when patients transition between healthcare providers, such as patients who are discharged from a hospital and go into a skilled nursing facility, and patients who are discharged from a hospital and go home.

As the Society of Hospital Medicine notes, performance problems linked to care transitions include adverse outcomes for patients, decreased patient and staff satisfaction, inappropriate use of resources, and reimbursement penalties. Any gaps in transitions of care will increase the likelihood that an organization will experience one or more of these issues.

Fortunately, there's a highly effective way to reduce and close such care transition gaps while also improving quality of care, increasing satisfaction, and better optimizing the usage of resources: involving pharmacists — and sometimes clinical pharmacists.

Here we'll discuss the role of pharmacists and clinical pharmacists and how their skills can uniquely lead to the closing care gaps. But first, let's gain a better understanding of transitions of care, why potentially harmful gaps and errors occur during transitions, and the ramifications of transitions of care gaps.

What are transitions of care?

The Centers for Medicare & Medicaid Services (CMS) defines transitions of care as follows: "The movement of a patient from one setting of care to another," with such settings including hospitals, ambulatory primary care practices, ambulatory specialty care practices, long-term care facilities, home health, and rehabilitation facilities.

Providing some context to the social impact of cost and quality into focus with care transitions, the Joint Commission adds, "Each transition of care is an opportunity to ensure better patient safety across the continuum of care, starting at admission to a healthcare facility, throughout the visit or stay, at discharge, and following through to the next care setting."

How do transitions of care gaps occur?

There are any number of factors that can contribute to the gaps in care coordination. Among those regularly cited in research include poor communication between care team members and with patients, an incomplete transfer of information during transitions, inadequate education of patients and their caregivers, limited access to the services that help facilitate safe transitions, and the lack of a designated care team member to help ensure continuity of care during transitions. Then, there are barriers that exist in many patients environment identified as Social determinants of health that can further exacerbate challenges to continuity of care.

One of the transitions of care most associated with gaps and shortcomings is the discharge process. The Commonwealth Fund has defined a hospital discharge planning gap. It states that a gap occurs when a patient is discharged from the hospital and:

  • does not receive written information about what to do when they return home and symptoms to watch for;
  • the hospital did not make sure the patient had arrangements for follow-up care;
  • someone did not discuss with the patient the purpose of taking each of their medications; and/or
  • the patient did not know who to contact if they had a question about their condition or treatment.

Unfortunately, care gaps are fairly common. Following a hospital stay, patients are commonly fatigued and overwhelmed and unable to retain discharge instructions they are provided at the time of discharge. Another common contributor is the discharge summary, which is often late or includes incorrect information. Overall, hospital discharge processes are complicated and inconsistent. Among the greatest hazards created by this discontinuity is the introduction of new medications into a patient's regimen and arrangement of a follow-up appointment with their primary care provider.

There are also shortcomings associated with one of the most important processes following discharge: medication reconciliation post-discharge (MRP). CMS defines MRP as "A type of review in which the discharge medications are reconciled with the most recent medication list in the outpatient medical record." Unfortunately, as we've previously noted, 40-50% of discharges do not have MRPs performed.

Why are transitions of care gaps such a serious problem?

Every care transition gap brings with it serious patient risks. When important patient information is overlooked, missed, or miscommunicated during transitions, the likelihood of an adverse event increases. One frequently cited study estimates that as much as 80% of serious medical errors involve miscommunication during patient handoff between medical providers. The Institute of Medicine found that half of all medication errors and one-fifth of adverse drug events in hospitals occur due to poor communication during transitions. AHRQ reports that in 2018, there were nearly 4 million 30-day all-cause adult hospital readmissions across all payers — a 14% readmission rate. Medicare accounted for about 60% and Medicaid accounted for 19%. Then there's the key patient safety issue of medication reconciliation, a process that must be performed properly during care transitions or the risk patient harm.

Healthcare organizations also face the potential for significant ramifications from gaps in their care transitions. As Health Affairs notes, researchers have estimated poor transitions caused between $25 billion and $45 billion in wasteful medical spending through avoidable complications and unnecessary hospital readmissions. AHRQ reports that the average readmission costs more than $15,000. Kaiser Health News reports that Medicare recently cut payments to nearly half the nation's hospitals due to excessive patient readmissions.

Finally, transitions of care also take on importance concerning healthcare quality scores. In 2018, the National Committee for Quality Assurance added transitions of care to the Healthcare Effectiveness Data and Information Set (HEDIS®), reports The Journal of Healthcare Contracting, while in 2022, CMS announced the introduction of transitions of care as a new Star Rating measure intended to promote better care coordination across the field, reports AJMC.

Eliminating Care Transition Gaps With Pharmacists

Now that we have a better understanding of transitions of care, how gaps occur, and why these gaps are such a significant problem and concern, let's explain why involving pharmacists and clinical pharmacists, when appropriate, in transitions of care are proving to be some of the most effective ways to reduce gaps and patient safety risks.

Pharmacists are medication experts

Most importantly, there is likely no one more qualified to discuss medications with patients and fellow care team members than pharmacists. As Rhonda Waskiewicz, dean of the College of Health and Pharmacy at Husson University told U.S. News & World Report, pharmacy schools typically have significant academic prerequisites. Most schools of pharmacy require a strong background in biology, chemistry, anatomy and physiology, and math prior to entering the program. A pharmacist becomes a medication expert and resource to support the care team thanks to their detailed understanding of the chemical and biological functions of the body and how drugs being prescribed contribute to positive outcomes.

Clinical Pharmacist Meghan Smart, PharmD, BCMTMS, INHC, RYT, states, "Pharmacists are the medication experts on the healthcare team. We spend extensive time learning about medications and refining the team's practice of executing and effective transition of care experience for the patient."

When patients or care team members have questions or concerns about medications, they will be best served by speaking with a pharmacist. Healthcare organizations should have a pharmacist available for these conversations during internal care transitions and following discharge.

Pharmacists possess other valuable skills, as Zarah Mayewski, PharmD, BCPPS, director of Cureatr Clinic, states. "Pharmacists are great listeners, detail-oriented, and bring unique expertise and skill set to the healthcare continuum. We have the deepest knowledge of how medications work, what their side effects are, what they will adversely react with, and how each patient's unique situation can drastically change the efficacy of the drugs that are prescribed. There is a complex interplay of variables that need to be balanced for each person's medications to make the most positive impact in the patient's life."

Pharmacists are in the best position to perform proper medication reconciliation

We've touched on the importance of medication reconciliation. To better ensure med rec is performed correctly and to maximize the benefits of this essential process for avoiding medication errors, organizations should often assign this task to pharmacists.

As Clinical Pharmacist Tram Thai, BCACP, AE-C, states, "Medication reconciliation is designed to avoid common medication errors, but it's not always as easy as it sounds. … this is where I think the clinical pharmacist can play a huge role. If you think about med rec, it's a step-by-step approach that includes verification, so we collect accurate medication history; clarification, where we ensure that the medication and doses are appropriate; and then reconciliation, where we document every change and make sure that it all checks out with the other medications and patient information."

Pharmacists should be tasked with performing MRP

If hospitals hope to reduce readmissions, medication reconciliation post-discharge must be performed consistently. Any missed MRP increases the likelihood of a readmission.

As with medication reconciliation, pharmacists are often in the best position to perform MRPs. For subsets of complicated patients, clinical pharmacists offer the best strategic approach to avoid complications and maximize patient benefit. Hospitals lacking staff who can perform medication reconciliation post-discharge for such complicated patients can partner with an organization like Cureatr and leverage its Cureatr Clinic team of board-certified, residency-trained clinical pharmacists and pharmacy technicians. One random controlled trial at a 4-star hospital system showed that Cureatr was able to achieve a nearly 57% reduction in 30-day readmissions for congestive heart failure patients who received the company's MRP service.

What's particularly important about performing effective MRP, as Dr. Thai states, is going beyond med rec. "Sometimes when you hear the term MRP, you think the process only involves reviewing medications and making sure patients are taking them, which oftentimes is all that is done. At Cureatr, we are striving to do more than that. There are always more issues that the patient needs help with that either we can help resolve or at least find someone who can help. The MRP is really just a baseline of the service. All the other issues that come to the surface when we're talking to the patient allow us to set the patient up for success in managing not only their medication but their overall health."

In her interview, Dr. Thai shares three experiences where her work providing medication reconciliation services and additional support led to improved health outcomes and patient satisfaction. These concern a drug-to-disease state interaction, a medication access problem, and helping a patient who was struggling to get the care support they felt they needed.

Cureatr Clinic's clinical pharmacists are allocated the time they need to take a deep dive into a patient's medications and the other issues and factors that can make a difference in helping patients access the medications and support services they need. This leads to strengthened medication adherence, decreased readmissions and costs, boosted quality scores, and ultimately improved outcomes and financial performance.

Pharmacists often have more details on a patient's medications

As noted, considering pharmacists' work revolves around medications, they will likely have the best access to information about and understanding of patient medications. It's best when internal medication information is supplemented by external data, such as the information provided by a platform like Cureatr's Meds 360°.

Greater therapeutic benefits and avoided readmissions come from the adjustments and tailored therapeutic problem-solving pharmacists are in the best position to provide. With their training, experience, and access to medication data, pharmacists serve as a vital member of the care team, with their role taking on further significance when care involves powerful medications designed to be applied to specific clinical indications.

Filling In Your Transitions of Care Gaps

Reducing transitions of care gaps is essential to strengthening medication management, which delivers significant benefits to the patient experience and improves overall health and health outcomes. Cureatr Clinic has the expertise, data, and technology to provide a broad spectrum of clinical services to patients in need. Learn about our clinical services, then schedule a time to speak with one of our consultants.

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