Transitions of care (TOC) have emerged in recent years as an area of high vulnerability for patients — one where errors and poor or lack of oversight often lead to harm, worsening outcomes, and increasing readmissions. The recognition of TOC, sometimes abbreviated as "TRC," as a high-risk process has spurred increased attention to the set of actions required for effective care transitions. This increased recognition of the importance of transitions of care has also motivated the National Committee for Quality Assurance and the Centers for Medicare & Medicaid Services (CMS) to develop a HEDIS® measure and quality measure (respectively) focused on TOC.
While much has been written about the ways our healthcare system can improve transitions of care, we wanted to focus on an area that's receiving greater recognition as one of the most effective ways to achieve meaningful improvements: the incorporation of a transitions of care pharmacist into the interdisciplinary care team.
Read on to learn about this vital position and the different transitions of care pharmacist models organizations are leveraging to achieve more ideal TOC processes and performance.
Role of a Transitions of Care Pharmacist
A transitions of care pharmacist is also referred to as a transitional care management pharmacist, transitional care pharmacist, and other like terms. While the way they're described may differ from one organization to another, TOC pharmacists are expected to play a pivotal role in supporting and overseeing care transitions.
What are care transitions? CMS provides a simple definition, stating, "Care transitions occur when a patient moves from one healthcare provider or setting to another." An article in the Journal of Perioperative & Critical Intensive Care Nursing provides a more detailed description of transitions in care, stating these "typically describe a change in healthcare as patients move between multiple care settings — for example to and from the operating room or intensive care unit — and most commonly refers to the time when patients are discharged from the hospital setting."
Why are transitions of care such an important area of focus? CMS reports that nearly one in five Medicare patients discharged from a hospital — approximately 2.6 million patients — are readmitted within 30 days, at a cost of more than $26 billion annually. By improving transitions of care, organizations can prevent unnecessary readmissions and hospitalizations. Furthermore, effective care transitions also reduce medical and medication errors, identify opportunities for interventions, and avoid duplication of services.
So, where does a transitions of care pharmacist fit in? Like their titles, responsibilities for a TOC pharmacist will vary from organization to organization, but essential responsibilities for these professionals tend to focus on the areas where pharmacists excel: pharmacy services and medication management. As Clinical Pharmacist Meghan Smart, PharmD, BCMTMS, INHC, RYT, notes, "Pharmacists are the medication experts on the healthcare team. Medication management is what we do. We spend so much more time learning about medications and refining our expertise in this area than anybody else on the healthcare team."
It's typical to see a transitions of care pharmacist tasked with responsibilities that often include the following:
- Assist with and/or perform medication reconciliation and medication reconciliation post-discharge (MRP)
- Collaborate with the patient, patient's caregiver, patient's care team, and/or interdisciplinary team to identify and address medication access barriers
- Support efforts to strengthen care coordination between settings and providers
- Deliver medication-related education and counseling to patients and caregivers
- Provide follow-up support to patients and caregivers to help reduce readmissions, especially for high-risk patients, such as those with multiple chronic conditions and complex medication regimens
- Help identify opportunities for organizations to reduce the likelihood of medication-related errors and oversights
While the list of responsibilities for a transitions of care pharmacist can grow much longer, the value these professionals bring to a care team and services they provide are best maximized when organizations recognize them as medication management experts. Such recognition should motivate organizations to look for ways to ensure TOC pharmacists are put in the best position to improve care transitions and support patients during transitions and in the period immediately following discharge where the risk of readmission is highest.
As Hospital Case Management reports, research has demonstrated that including pharmacists on transitions of care teams help organizations improve outcomes and meet patient care goals
Transitions of Care Pharmacist Models
As appreciation for the role that a transitions of care pharmacist can play in supporting patients and care teams has grown, so have the different ways that TOC pharmacists are being incorporated into a patient's journey.
Here are a few of the most common transitions of care pharmacist models in use today.
Telepharmacy support for providers
For healthcare organizations looking to reap the benefits of involving one or more transitions of care pharmacists in patient care without expanding its internal staffing, there are companies ready to help. For example, Cureatr, through the Cureatr Clinic, provides scalable clinical telepharmacy services delivered by clinical pharmacists and pharmacy technicians. These pharmacy professionals are available to support an organization's internal care team as they transition patients through the care continuum. When patients — typically those identified as higher risk and with more complex medication regimens — are discharged, Cureatr Clinic team members take the lead on medication management, performing services like those identified above, including MRP, condition-specific comprehensive medication management, deprescribing, and patient education.
Internal transitions of care pharmacists
Some healthcare organizations are hiring TOC pharmacists and elevating existing pharmacy team members into these positions. These positions can be further supported through the development and launching of a pharmacy transitions of care (PTOC) program. A case study published in the American Journal of Health-System Pharmacy showed that a PTOC program that integrated two transitions of care pharmacists reduced 30-day readmission rates for Medicare core-measure patients.
Some organizations with TOC pharmacists and PTOC programs are supplementing them with an external telepharmacy service to help ensure there's always effective care transition support for those patients who will benefit from medication management services.
Telepharmacy support for payers
Providers aren't the only ones recognizing the value of transitions of care pharmacists. A growing number of payers are contracting with a telepharmacy service provider to support their members. In this transitions of care pharmacist model, the pharmacist largely focuses on supporting members with a complex medication regimen when they are most likely to experience a change to their regimen, such as following discharge from a hospital or visit to an urgent care clinic. Telepharmacists connect with patients to perform MRP, reduce medication errors, and mitigate interactions, thus helping decrease readmissions and raising a health plan's quality scores.
Direct support for patients
Some providers and health plans are going even further in leveraging transitions of care pharmacists by contracting with a virtual pharmacy clinic that is then available to provide direct support to patients/members and their caregivers. Through this service, patients receive an initial phone consultation during which a pharmacist reviews current medications, discusses a patient's health goals and how medications support them, addresses medication-related questions, and provides an action plan focused on optimizing the regimen and achieving treatment goals. Following that medication consultation, the patient receives ongoing check-ins and support from a pharmacist to keep them on track with the medication plan and health goals while helping prevent avoidable and costly admissions and services. In addition to such routine services and support, these pharmacists are available to patients and caregivers when patients experience care transitions and modifications to their medication regimen.
What Can a Transitions of Care Pharmacist Do for You?
The average cost of a readmission exceeds $15,000, and every readmission puts patients at greater risk, further strains healthcare staff and resources, and increases the likelihood of financial penalties for providers. The usage of transitions of care pharmacists is proven to be one of the most successful ways of preventing readmissions while also improving patient health and satisfaction with their care — benefits that help providers, payers, and the healthcare system as a whole.
Interested in learning how your organization can effectively and efficiently incorporate transitions of care pharmacists and telepharmacy? Schedule a consultation with Cureatr. We'll explain how we combine of data, technology, and expert pharmacist services that will help you solve the medication management puzzle.