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The pharmacist's role in care transitions

November 8, 2011
by Erin Graves, PharmD, Kelly A. Hollenack, PharmD, CGP, and Marsha J. Meyer, PharmD, CGP, FASCP
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Alfred, a healthy 81-year old, was hospitalized for a knee replacement. He was started on a blood thinner to prevent blood clots following surgery. Shortly thereafter, he developed symptoms suggestive of internal bleeding. The blood thinner was stopped pending testing. Meanwhile, Alfred was transferred to a rehab facility. Three days later, he was lethargic, experiencing chest pain, difficulty breathing and was subsequently sent to the emergency room. He was diagnosed with multiple blood clots. Testing for possible internal bleeding had never been completed

and the rehab facility did not question his post-surgical transfer orders, which were missing a blood thinner. Missed opportunities from both the discharging and receiving healthcare providers caused not only a re-hospitalization, but almost cost Alfred his life.

A “transition in care” is defined by the American Geriatrics Society as a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location. Successful transitional care depends upon a comprehensive treatment plan, shared by healthcare providers at both the transferring facility and the receiving facility or community-based provider(s). Clinicians, well-trained in chronic, complex care needs and focused on the patient's goals, preferences and evolving clinical status, are mandatory. A successful transition of care moves beyond the obligatory medication reconciliation and includes patient and caregiver education and extensive coordination of services between the healthcare professionals involved in each transition.


More than 25 percent of nursing home residents use emergency department (ED) services annually. Subsequent to their ED experience, many patients are admitted to acute care hospitals and then transferred to long-term care settings for either post-acute or extended care. After a period of recovery and rehabilitation, many are discharged from the LTC setting, transitioning back to their homes. High rates of transitioning between healthcare sites were documented in a study of post-acute and SNF settings. During a two-year period, almost 5 million individuals, aged 65 and older, made more than 15 million transitions of care. More than 1.1 million of these patients required subsequent healthcare utilization (e.g., ED visits, potentially avoidable hospital stays and returns to an institutional setting after discharge to the community). To put it another way, nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days, representing more than 2.6 million seniors and at a cost of more than $26 billion annually.


In response to this growing problem, the federal Department of Health and Human Services launched the Partnership for Patients program in April 2011. One major goal of the partnership: Help patients heal without avoidable problems (preventing complications during a transition of care). By the end of 2013, the program hopes to reduce hospital readmissions by 20 percent compared to 2010.

The Affordable Care Act also targets poor transitions of care, aiming to reduce unnecessary hospital readmissions by 20 percent. Beginning in 2012, hospitals will have their reimbursement cut for readmissions of Medicare beneficiaries within 30 days of discharge.

Additionally, health plans covering Medicare Part C recipients will be measured in 2012 based on 30-day hospital readmission rates. Plan ratings are displayed in the Medicare Plan Finder (MPF) tool on

Hospitals will not be successful in this endeavor alone; successful transitions of care require substantial collaboration between the discharging facility and the admitting facility and/or community service providers. Hospitals will partner with the LTC facilities that produce the lowest readmission rates. Skilled nursing facilities will become, directly or indirectly, part of an accountable care organization (ACO) with the hospital.


LTC patients, by virtue of their high level of medical complexity and functional impairments, are at heightened risk for complicated transitions of care. An evolving treatment plan-constructed with carefully identified problems, goals and interventions-should follow the patient throughout each step of the transition, unifying healthcare providers in their continuing support for the older adult.

Several transitions of care involve the LTC facility: either an existing LTC patient transfers back to the facility from a hospital stay or the temporary post-acute or rehab resident transitions back into the community. A successful LTC transition program must address both ends of the spectrum, with the goals of becoming both a good hospital partner with low readmission rates and a good community partner, coordinating care with local healthcare providers and services for a successful return to home.


Multiple effective short-term transitional models demonstrating reductions in 30- and 60-day hospital readmission rates and total healthcare cost savings have been documented. Leaders at LTC facilities seeking to develop their own transitional care program can study these pilot programs as well as other transition program models for guidance (see Suggested Reading).

The National Transitions of Care Coalition (NTOCC) has recommended key changes to the traditional transition of care model, which will hopefully optimize (medically and financially) the newly evolving transitional process. Recommendations include: