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As patients navigate through the healthcare system, there is both a need and an opportunity to support safe and effective transitions of care. The potential for complications such as medication errors and adverse events arise as patients transition from one care setting to another. Poor communication between healthcare providers, lack of standardized processes, and discrepancies in electronic health records contribute to ineffective care transitions. However, this is especially problematic when discharging from hospital to another care setting, which can lead to unwanted outcomes including medication errors and hospital readmissions.1,2

In 2012, the Center for Medicare & Medicaid Services (CMS) implemented the Hospital Readmission Reduction Program (HRRP), which penalizes hospitals for excessive readmissions. Hospitals receive a reduction in payment for all-cause readmission within 30 days for patients with applicable conditions, including pneumonia, heart failure, myocardial infarction, chronic obstructive pulmonary disease, and hip or knee arthroplasty.3 As a result, healthcare institutions have an invested interest to improve transitions of care in an effort to reduce hospital readmissions and improve healthcare outcomes.

Transitions of care at hospital discharge requires a multidisciplinary effort and involves bridging the gap between inpatient and other care environments. The pharmacist can play a valuable role in supporting patients during transitions of care. Contributions include comprehensive discharge planning, medication reconciliation, discharge education, addressing access barriers, and care coordination to ensure appropriate follow-up and monitoring. A pharmacist providing transitions of care services in the hospital setting must have knowledge and training in how to navigate both the inpatient and outpatient healthcare environments to effectively provide these services to their patients.

Comprehensive discharge planning should begin early on in admission to anticipate and address barriers to discharge. A collaborative interprofessional approach should incorporate the unique needs of each patient in creating and implementing a plan and appropriate follow-up. Patient-specific needs may vary based on their discharge disposition, level of independence and caregiver support, functional and cognitive capacity, and financial resources. For example, identifying a patient started on a known expensive brand name medication or one that is known to carry outpatient formulary restrictions allows time to triage and address those issues prior to discharge to ensure medication therapy is not interrupted. As healthcare providers reconcile medications, provide education, and support continuity of care, they should consider what support the patient requires to safely transition to their next care setting.

Medications should be reconciled at the time of admission, during transfers, and upon hospital discharge.4 An accurate best-possible medication history (BPMH) which identifies medications the patient was taking prior to admission is imperative for patient safety as well as to limit unnecessary interruption in medication therapy during hospitalization. It also ensures a smoother discharge and prevents medication errors.5 Discharge medication reconciliation involves comparing the medications ...

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