Karen Trenkler, PharmD, MS, BCPS
Pharmacy Clinical Coordinator
Justin Schneider, PharmD
Pharmacy Director Mount Sinai Hospital/Sinai Health System
Chicago, Illinois

The term transitions of care was introduced to most of the health care world as a concept relatively recently; however, elements of transitions of care are not new concepts to health care practitioners. The importance of reviewing the medication profile at both admission and discharge (or any change in level of care within a given hospitalization), patient education in the hospital in preparation for the ambulatory care setting, and counseling for discharge were identified more than 2 decades ago as areas that presented opportunities to improve care. The execution of transitional care provides a perspective of movement of the patient through the care process. It integrates each element with the objective of ensuring patient transition in a seamless manner, thereby optimizing therapy. Each care transition step warrants evaluation and possible action by a pharmacist, especially for high-risk patients. The linking of readmission rates to Centers for Medicare & Medicaid Services reimbursement likely has fueled recognition of the importance of transitions of care.

Mount Sinai Hospital in Chicago established a program to foster transitions of care as part of an effort to reduce readmission rates for several chronic disease states. The efforts to reduce readmission rates at this urban safety-net hospital were initiated with a pilot program targeting heart failure (HF) in 2011. A pharmacist was incorporated into a multidisciplinary pilot team that included representatives from the medical, nursing, social work, dietary, and physical therapy staffs.

The pilot—implemented using Project Re-Engineered Discharge, or Project RED—was conducted without additional pharmacy staff. The pharmacy clinical coordinator, in conjunction with Advanced Pharmacy Practice Experiential (APPE) students, worked with pilot patients. Over time, the processes to be accomplished by pharmacists were defined and executed. These processes included conducting medication histories and medication reconciliation, educating patients, optimizing pharmacotherapy, conducting medication reconciliation at discharge, and contacting patients at home after discharge. Not only does involving pharmacists reinforce each separate component of the process, but it also is a logical and effective approach to ensuring safe and effective patient care over the care continuum (Figure).

Transition From Home to Inpatient Setting

Medication Historya

(Student or pharmacist, after admission, in ED or on unit)

Discussion: b,c

  • Medication history
  • Medication “experiences,” including ADEs, tolerance, and compliance
  • Contact patient’s pharmacy if needed
  • Evaluate for drug-related causes of exacerbation (eg, noncompliance, suboptimal dose or selection, drugs that directly worsen HF)

Medication Reconciliationa


Education, Phase I

(Student or pharmacist)

  • Assess patient knowledge of disease and medications
  • Consider initiating an educational session, depending on patient’s health status and knowledge base

Inpatient Setting

Education, Phase II

(Student or pharmacist)

  • Discuss disease and medications
  • Discuss ADE and symptom recognition
  • Use teach back techniques to ensure patient understanding

Pharmacotherapy/medication Optimization Considerationsd

(Pharmacist and interdisciplinary team)

  • CMS standards (ensuring ACEI/ARB use)
  • Medication selection
  • Prescription insurance coverage
  • Dose optimization
  • Titration issues—getting to goal
  • ADEs

Discharge Processed

(Pharmacist and physician)

  • Discharge medication list is completed by physician
  • Decentralized pharmacist monitors discharge plans

Medication Reconciliatione

(Pharmacist or PGY1 pharmacy resident)

  • Review discharge medications
  • Depending on timing of discharge, this may be accomplished post-discharge

Transition From Inpatient Setting to Home

Post-discharge Contact

(PGY1 pharmacy resident)

  • Phone call to patient post-discharge (up to 3 attempts)
  • Goals of contact
  • Ask patient to read directions from prescription bottles
  • Verify medication supply
  • Ascertain compliance
  • Review ADEs and HF symptoms
  • Provide further educational opportunity, if needed

Follow-Up as Needed

(PGY1 pharmacy resident)

If issues arise, follow-up with discharge coordinator, physician, or other providers, if needed

Figure. The transition from preadmission to hospital inpatient to post-discharge.
ACEI, angiotensin-converting enzyme inhibitor; ADEs, adverse drug effects; ARB, angiotensin receptor blocker; CMS, Centers for Medicare & Medicaid Services; HF, heart failure; PGY1, postgraduate year 1
a Movement from preadmission to inpatient status is executed by pharmacist or student with pharmacist oversight via medication history, then medication reconciliation.
b For HF patients, the medication list is evaluated for ACEI/ARB and β-blocker dose optimization, as well as with respect to medications with the potential to exacerbate HF.
c Initial discussion with the patient affords the opportunity to assess knowledge of disease and drugs. For knowledgeable patients, education may be handled during the initial meeting. Also, the initial discussion with the patient may point to ADEs versus symptoms of HF exacerbation.
d Pharmacists work toward pharmacotherapy optimization, with the medical team. The discharge medication list is completed by a medical resident or attending physician; a clinical pharmacist monitors progress toward discharge completion.
e Given that discharge may occur abruptly, discharge reconciliation may not always be completed before discharge. If reconciliation is not completed before discharge, more detail must be obtained post-discharge from the medical record (eg, discharge instructions and medication list, with a focus on new medications added to the profile) before contacting the patient.

The post-discharge phone call was a new function for the pharmacist. The pharmacists enhanced the usefulness of the post-discharge call by focusing on key information, including prescriptions not filled (eg, due to a missing script or coverage/funding issues), potential adverse effects versus HF symptoms/exacerbation, and the need for more education.

During the pilot period, tasks for pharmacists were broken into modules, with specific components of the process defined. A data-recording tool, specific to the data collection requirements of the pharmacist, was designed and implemented. This tool served to both prompt appropriate action by pharmacists and to record key information for the pharmacists completing the post-discharge phone call and in the event of a subsequent readmission. Data fields included preadmission compliance, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker tolerance, dose titration for optimization, and others.

As the pilot evolved into a program, patient numbers and pharmacist functions increased and the pharmacy process was reconfigured. At that point, a transitions of care longitudinal postgraduate year 1 (PGY1) rotation was established, to expose the pharmacy residents to this emerging area of practice and to meet the patients’ needs. Documentation of success, based on a reduction in HF-related readmissions, led to expansion of the program to include diabetes in 2012. This expansion of the program resulted in further modification of pharmacists’ roles and responsibilities to incorporate the clinical pharmacists more extensively, in addition to PGY1 residents.

Measuring the Pharmacist’s Role

The Mount Sinai team analyzed its program to foster transitions of care and reduce HF readmissions, presenting the data at the 2012 Midyear Clinical Meeting of the American Society of Health-System Pharmacists. The group examined data to determine the extent of pharmacist interventions and to examine the overall and relative effectiveness of the iterations of the process used. The 3 phases—the pilot phase; the phase primarily handled by the PGY1 pharmacy residents; and the current hybrid phase, which uses both clinical pharmacists and the PGY1 pharmacy residents—extended for variable durations, with varying numbers of patients. The pilot phase lasted 6 months and covered 62 admissions and 51 patients; the phase primarily managed by PGY1 residents lasted 8 months and covered 115 admissions and 100 patients; and the hybrid phase, which uses a coordinated effort between clinical pharmacists and residents at the time of the analysis had lasted 2 months and covered 32 admissions and 27 patients. In the care of 209 admissions, on a per-patient basis, the overall number of interventions by pharmacists was 3.8, with the highest intervention rate of 4.1 per patient, achieved with the current hybrid state.

Ultimately, the focus of the program is patient outcomes. The multidisciplinary team significantly and consistently affected readmissions, demonstrating a decrease in the 30-day HF readmission rates from 17.6% to 7.8%. Although it is difficult to isolate the contributions of specific professionals on the team, it is generally recognized that HF is a disease that is heavily medication-centric. The multidisciplinary team worked together seamlessly, meeting and communicating frequently. The phone call to the patient subsequent to discharge, which extends the role of the inpatient pharmacist into the ambulatory care setting, was deemed to be a worthwhile effort.


At the outset, the team recognized the need to strengthen the connection to the ambulatory care setting but was confronted with limitations in communicating with nonaffiliated clinics and independent practitioners. Clearly, this is an area warranting further study and effort to ensure optimal care for patients not integrated fully into the health system.

Efforts early in the program resulted in the addition of one full-time equivalent (FTE) pharmacist. This position was integrated into the decentralized pharmacist team to expand departmental contributions to the transitions of care. Demonstration of continued effect resulted in the very recent granting of a 0.5 FTE ambulatory care position. The imminent expansion to diseases beyond HF (ie, diabetes and chronic obstructive pulmonary disease) will facilitate the optimization of care for a far greater number as well as different types of patients.

A focus on transitions of care bridges the ambulatory care setting to the inpatient setting and then back to the home or another facility. As executed at Mount Sinai Hospital, it includes optimizing admission, planning for chronic disease management, optimizing inpatient stay, patient education, preparing for discharge on or shortly after admission, and ensuring connections to the patient’s home, post-discharge.

Pearls for Setting Up A Care Transitions Program

  • Pharmacists have an essential role in the transitions of care, given the significant role of pharmacotherapy, in general.
  • Students, appropriately supervised, can serve as extenders of care.
  • Definition and modularization of processes can delineate the necessary steps and allow for workload (re)distribution, with minimal effect on the subsequent effectiveness of processes.
  • Pilots allow demonstration of potential accomplishments. Even without designated resource allocation, a pilot can effectively demonstrate value and generate resources for that effort in the future.
  • Documentation and measurement of pharmacist contributions is a key aspect of pharmacy practice and can facilitate an expanded role for pharmacists.