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Development and implementation of a transitions of care service in an ambulatory care setting in collaboration with a primary care physician

Rachel J. Pucel, PharmD, CTTS, Michael J. Rush, PharmD, CDE, BCACP, CTTS, Karen L. Kier, PhD, MSc, RPh, BCPS,BCACP
Ohio Northern University

Transitions of care from a hospital to primary care physician’s (PCP’s) office have been characterized as “unsystematic, non-standardized, and fragmented” by the National Quality Forum.  It is well documented that adverse drug events occur frequently during periods of transition, which may subsequently lead to unnecessary hospitalizations.  The readmission rates for Medicare beneficiaries are around 20% within 30 days of discharge, with 50% of patients lacking a visit with their PCP between hospitalizations.  Hospitals will soon be financially penalized for these unnecessary readmissions due to the CMS Hospital Readmissions Reduction Program.  Lack of coordination in the handoff from hospital to outpatient care, financial limitations, incomplete sharing of health information and staffing shortages are several challenges to implementing transition of care services.  Various models have been implemented using hospital pharmacists performing medication reconciliation, discharge counseling, and coordination with outpatient follow-up.  However, efforts need to be streamlined to the outpatient setting to help ensure patients have appropriate medication regimens and knowledge of their conditions following discharge.


The primary objective of this study is to assess the impact of a pharmacist-directed transitions of care (TOC) clinic in a PCP setting to reduce medication-related problems.  Our hypothesis is that when taking a proactive approach by scheduling follow-up appointments with the pharmacist at their PCP office following discharge from hospital, medication-related problems will be reduced quickly and effectively through collaboration with their PCP.  Correcting these medication-related problems and providing patient education earlier rather than later may assist in reducing readmission rates.  The secondary objectives include the interventions recommended by the pharmacist and accepted in collaboration with the PCP.


The primary objective of this study will be accomplished through the following specifications: 1. Detect when patients are discharged from the hospital and schedule follow-up appointments in order to provide timely access to care following hospitalization;  2. Identify the number and type of potential medication-related problems for patients participating in the TOC clinic; 3. Assess the number of medication-related problems resolved during TOC appointment in collaboration with patient’s PCP; 4. Provide patient education to assess their knowledge of hospital course, disease states, medications, and importance of adherence.


For the practice’s established patients, a hospital discharge summary will be obtained within 72 hours of discharge, a pharmacist team member will provide initial screening and will schedule face-to-face and/or phone follow-up appointments within 7 days of discharge in collaboration with the PCP.  Utilization of Project BOOST’s 8P’s for risk assessment will determine the extent of follow-up provided.  High-risk patients will receive face-to-face appointments while moderate-risk patients will receive follow-up via phone call. During follow-up, the pharmacist will identify patient goals, provide medication reconciliation, counsel on medications and identify and resolve medication-related problems. Patient demographics, summarized discharge information, number of medication-related problems, type of medication-related problems including but not limited to duplicate therapy, wrong drug, wrong dose, medication indicated but not prescribed, lack of indication, medication allergy, and adverse drug events, number of interventions recommended, and number of interventions accepted by the collaborating physician will be documented.  All information will be de-identified and coded for statistical analysis.  Primary and secondary objectives will be analyzed using both descriptive and inferential statistics.  Data from the study will be compared with national statistics as well as published data.

ASHP Midyear Clinical Meeting, Anaheim CA- 12/2014
PDF icon toc_r_pucel_ashp_midyear.pdf1.36 MB