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The Centers for Medicare & Medicaid Services (CMS) define a transition of care as the movement of a patient from one setting of care to another. Healthcare transitions can include a change in service or level of care, a change in setting, or a change in provider.1 Ineffective transitions of care have consequences, including medication error and adverse events, excessive emergency department (ED) visits and avoidable readmissions, high costs to the healthcare system, and patient dissatisfaction.2 Among Medicare patients, almost 20% who are discharged from a hospital are readmitted within 30 days. Unplanned readmissions, at a cost of $17.4 billion, accounted for 17% of total hospital payments from Medicare in 2004.1

There is both a need and an opportunity to promote safe and effective transitions of care as patients navigate through the healthcare system. This requires an interdisciplinary approach to care, improved collaboration between healthcare providers, and implementing interventions that aim to reduce medication errors and adverse events. Goals of transitions-of-care interventions include reducing hospital length of stay and avoidable readmissions, decreasing cost to the patient and healthcare system, and improving patient satisfaction.2,3

The pharmacist plays a valuable role in supporting transitions of care through his or her involvement in medication reconciliation, patient education, comprehensive discharge planning, and follow-up care coordination.2,3 A multitude of published studies support pharmacist involvement in transitional care management of patients, and these efforts result in a reduction of overall and medication-related hospitalizations and ED visits. Other benefits elucidated in the studies include fewer preventable adverse drug events within 30 days of discharge, fewer medication discrepancies at discharge, and improved patient adherence and understanding of medication therapy.4,5

How to Use this Book: Students

High-risk patient populations, including the elderly and those with multiple comorbidities, often benefit most from transitions-of-care interventions. This casebook will prompt students to apply principles of transitions of care in the provision of patient care across different disease states and healthcare settings. With each patient case, students should apply evidence-based medicine and guidelines to provide patient care, while considering patient needs based on the healthcare setting where care is being provided and as they transition to other settings of care (e.g., being discharged from the hospital to home versus to a long-term care facility). Students should apply the Pharmacists’ Patient Care Process (PPCP) and collect, assess, plan, implement, and follow up while incorporating pharmacist interventions during transitions of care. As students answer questions, they should consider their rationale for why the selected answer was most appropriate given the unique needs of their patient.

How to Use this Book: Faculty

Faculty can assign patient cases and questions to students through the written text or online version available on Access Pharmacy ( Answer rationales can be provided to faculty upon request. We encourage faculty to prompt students to provide their rationale for selected answers and discuss why their choices are most appropriate given their patients’ unique needs at each setting during their transition of care.


1. +
Centers for Medicare & Medicaid Services. Community-based care transitions program. Available at Accessed July 29, 2020.
2. +
American Pharmacists Association. Transitions of Care Toolkit. December 2019.
3. +
American Pharmacists Association. Applying the Pharmacists’ Patient Care Process to Care Transitions Services. February 2019.
4. +
American College of Clinical Pharmacy, Hume  AL, Kirwin  J, Bieber  HL, Couchenour  RL, Hall  DL, Kennedy  AK,  et al. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012;32(11):e326–e337.  [PubMed: 23108810]
5. +
American College of Clinical Pharmacy,  et al. Process indicators of quality clinical pharmacy services during transitions of care. Pharmacotherapy. 2012;32(11):e338–e347.  [PubMed: 23108762]

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