Improving Transitions of Care from Hospital to Home: Impact of Pharmacist-to-Pharmacist Handoff and Early Pharmacist Follow-up on Patient Outcomes

ABSTRACT: Improving Transitions of Care from Hospital to Home: Impact of Pharmacist-to-Pharmacist Handoff and Early Pharmacist Follow-up on Patient Outcomes Background Significant evidence exists to suggest that improving the quality of care transitions positively impacts clinical and economic outcomes. Communication, medication reconciliation and care coordination have been identified as components of quality care transitions. Previous evidence suggests that inpatient pharmacists can prevent medication errors, decrease adverse drug events and reduce readmission rates by conducting medication reconciliation and counseling upon hospital discharge. The role of the ambulatory care (outpatient) pharmacist in improving care coordination and communication between the inpatient and outpatient settings has not been evaluated. Objectives The primary objective is to assess the impact of an ambulatory pharmacist-led transition of care program on 30- and 90-day all cause readmissions in high risk general medicine patients. Secondary objectives are to (1) quantify the number of medication-related problems identified by ambulatory care pharmacists during the implementation of the transition of care program (2) estimate the economic impact of medication-related problem resolution, and (3) assess the impact of the program on patient satisfaction with care.