The pharmacist’s role in care transitions

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:

  • Improve communication during transitions between providers, patients and caregivers.

  • Implement electronic medical records that include standardized medication reconciliation elements.

  • Establish points of accountability for sending and receiving care, particularly for hospitalists, SNF physicians, primary care physicians and specialists.

  • Increase the use of case management and professional care coordination.

  • Expand the role of the pharmacist in transitions of care.

  • Implement payment systems that align incentives.

  • Develop performance measures to encourage better transitions of care.


Intuitively, a successful LTC transition of care program must include medication management and involve a pharmacist skilled in the medication issues of older adults.

By 2020, seniors (over 65 years old) will comprise 16 percent of the population, yet will consume 49 percent of all prescriptions in the United States. Medication-related problems result in 23 percent of all nursing home admissions and 25 percent of all hospital admissions among the elderly. Since older adults are four times more likely to be hospitalized by a medication-related problem (of which more than 75 percent are preventable), the importance of having a pharmacist, specially qualified in geriatric pharmacotherapy, as part of the facility’s transition of care program cannot be overstated.

“Based upon the literature and our clinical experience, we’ve seen that many unsuccessful transitions stem from medication-related issues. We believe that having a pharmacist participate in the patient’s care during a transition-not only to reconcile medications but also to optimize the regimen and improve adherence-has played a key role in our success in reducing avoidable readmissions from the community back to the acute care setting,” notes Dr. Dellara Terry, medical director of Dovetail Health, a company focused on reducing unnecessary healthcare utilization.

The goals of the transition team pharmacist should be maximizing therapeutic outcomes while identifying, resolving and preventing medication-related problems throughout all aspects of any and all transitions. Prior to admission into long-term care, the pharmacist can perform a medication reconciliation, looking for possible errors and omissions in prescribed medications during the hospital/LTC transition. The pharmacist can also identify medications that are highly associated with falls and other debilitating problems and work with facility staff to

proactively develop a treatment approach to eliminate preventable ED and hospital visits. For short-stay residents, the transition team pharmacist can help develop a pharmaceutical care plan tailored specifically for the individual resident (e.g., pain relief so that a resident can meet treatment goals for physical therapy sessions, or changing sliding scale insulin to a routine regimen for the diabetic resident returning home). Transferring the discharged resident to a community-based senior care pharmacist for continuing medication management services is a value-added service to the older adult. There is no cost to the LTC facility for this referral, and it can be promoted as a service differentiator between competitor facilities. Today, a poor transition to home with a preventable readmission to the hospital or SNF does not lead to direct financial penalties to a LTC facility, but may negatively impact marketability within the community, resulting in lower referrals from other healthcare providers. Traditionally referred to in long-term care as “consultant pharmacists,” these specially trained pharmacists have migrated beyond the nursing home walls and now practice in a wide variety of other settings, including sub-acute care, assisted living facilities, psychiatric hospitals, hospice programs and in community-based care-wherever seniors reside. In home and community-based care they are frequently referred to as “Senior Care Pharmacists.” Regardless of where they work, these pharmacists all share a common commitment to enhance the quality of care for all older persons through the safe and appropriate use of medications and promotion of healthy aging. To find a Senior Care Pharmacist in your community, visit the American Society of Consultant Pharmacists at


The American Society of Consultant Pharmacists empowers pharmacists to enhance quality of care for all older persons through the appropriate use of medication and the promotion of healthy aging.

Acknowledgement: The authors wish to thank Dovetail Health for its assistance with identifying post-hospitalization care transition models.

Erin Graves, PharmD, is a Senior Care Pharmacist and Co-Founder/Chief of Operations and Clinical Services for Medication Therapy Solutions, Inc., Houston. She can be reached at Kelly A. Hollenack, PharmD, CGP, is a Clinical Pharmacist with Humana Pharmacy Solutions, Clinical Strategies, Dublin, Ohio. Marsha J. Meyer, PharmD, CGP, FASCP is a Senior Care Pharmacist and Founder of SeniorMedHelp, Irvine, Calif.


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Long-Term Living 2011 November;60(11):20-23

Topics: Articles , Clinical