Integrating Pharmacists to Improve Transitions of Care Beyond Medication Reconciliation

By: Cheri Lattimer RN, BSN
Executive Director, National Transitions of Care Coalition 

The Centers for Medicare & Medicaid Services (CMS) defines a transition of care as the movement of a patient from one setting of care to another. Settings of care may include hospitals, ambulatory primary care practices, ambulatory specialty care practices, long-term care facilities, home health, and rehabilitation facilities. To improve these transitions, our health care system needs strong interdisciplinary care teams to collaborate and establish processes that improve transitions at each level of care within the health care continuum. 

The COVID-19 era in health care has seen unprecedented changes and that has been no different for the pharmacy profession. The profession has stepped up and played a more highly visible role in advancing public health than possibly ever before. Going forward, as we envision a post-COVID-19 pandemic world, the pharmacy profession will be better positioned to bring new levels of transformational care to the public.¹ Pharmacists have a crucial role and impact in improving transitions of care for patients, their identified family caregivers, and providers within the health care system. Pharmacists addressing the issues surrounding transitions of care have the opportunity to: 

• Improve the quality of patient care
• Reduce avoidable hospital readmission
• Enhance patient engagement
• Improve communication with patients and their identified caregivers
• Decrease medication errors

When we think about pharmacists working to address transitions of care, we tend to think their focus is medication reconciliation. However, pharmacists have so much more to offer in ensuring the safe use of medications by patients and their identified family caregiver with a focus on the patient’s plan of care. They are able to offer follow-up calls with patients, after nurse-based patient education upon a hospital or post-acute discharge, reinforcing medication continuity and ensuring the patient and their family caregiver have the opportunity to ask questions and clarify important medication care plans. 

In 2014, the Joint Commission of Pharmacy Practitioners published a paper describing the Pharmacists’ Patient Care Process. The Patient Care Process focuses the pharmacists to use a patient-centered approach to addressing the issues of Medication Management Services (MMS) and optimizing the patient’s health. Through this process, pharmacists develop a patient-pharmacist relationship that supports engagement and enhanced communication with patients and their identified family caregiver. In collaboration with the patient’s care team, the pharmacist is able to document and communicate with other care providers in the provision of safe, effective, and coordinated care.² 

In 2021, the National Transitions of Care Coalition (NTOCC) brought together a Transitions of Care Pharmacists Task Force to discuss the issues and concerns for pharmacists addressing transitions of care and what support pharmacists needed for this critical role. The Task Force believed there needs to be education and awareness in the health care industry of how integrating pharmacists into the transitions of care process can improve patient care and clinical outcomes. NTOCC has now convened the TOC Pharmacists Advisory Committee who will build on the work of the Task Force and the 10 Principles of TOC Pharmacists3 that were developed by the Task Force. The Committee looks to increase not only the awareness of the pharmacist’s role but bring awareness to the need for reimbursement models which would recognize the unique and valuable role and expertise the pharmacist brings to each care transition through their assessment, management, monitoring, and advocacy. 

Pharmacists should be an integral member of the interdisciplinary care team at every level of care transition and coordination. Although no one discipline is responsible for care transitions and coordination, a larger involvement by pharmacists beyond medication reconciliation will help realize an improved standard of care, including Medication Management Services, and overall quality of care as well as patient satisfaction and safety. 

References:
1. NTOCC January 2022 IMPACT, https://www.ntocc.org/news-1/nbsppharmacist-transitions-of-care-task-force-advancing-a-new-standard-of-care-in-our-post-covid-19-era-of-healthcare
2. JCPP Pharmacists' Patient Care Process, https://jcpp.net/wp-content/uploads/2016/03/PatientCareProcess-with-supporting-organizations.pdf
3. TOC Pharmacists 10 Principles, https://www.ntocc.org/health-care-professionals

Learn more about integrating the TOC Pharmacist into the care team and join me at ABQAURP’s 2022 Annual Health Care Quality and Patient Safety Conference in Clearwater Beach, FL on October 6-7, 2022. For more information and to register, visit: www.abqaurp.org/AnnualConference.

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