Transitions of Care

By Joel C. Marrs, Pharm.D., BCPS (AQ Cardiology),

CLS; and Sarah L. Anderson, Pharm.D., BCPS
Reviewed by Teresa M. Maddalone Swift, Pharm.D., BCPS; and Lisa C. Hutchison, Pharm.D., MPH, FCCP, BCPS

Learning Objectives

Geriatrics Society defines transitional care as a set of

actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same
location. Transitions can occur during either acute or
chronic illness and often involve many parties, including
the patient, the patients family members or caregivers,
social workers, and health care providers (e.g., physicians,
physician assistants, nurses, pharmacists, occupational
therapists, physical therapists). Comprehensive, effective
transitional care addresses both acute and chronic patient
needs and provides for continuity of care as the patient
transitions between providers and settings.
Unfortunately, care transitions can be abrupt and
unplanned, leaving patients and their family members or
caregivers unprepared to function safely and effectively
in their new environment. When transitioning from the
outpatient to the inpatient setting, patients are often not
continued on their home drug regimen because of institutional formulary issues or medical necessity. Because
the patient is in a new, unfamiliar environment, changes
in drugs and daily routines can be confusing and concerning. When ready for discharge, patients may receive
inadequate education on drugs, diet, and self-care that
renders them ill equipped to transition from dependent to independent management of their health care.
Health care providers may have trouble recognizing
when patients lack the knowledge, skills, or finances

1. Identify the prevalence of transitions of care in the

current U.S. health care system.
2. Evaluate risk factors and predictors of poor outcomes related to transitions of care.
3. Distinguish the various types of care transitions
to which patients are exposed in the current U.S.
health care system.
4. Assess and evaluate areas that health care providers
can screen for to potentially prevent negative outcomes related to the transition of care process.
5. Design an approach to improving the transition
of care process through established performance
measurements, and identify how these measurements can be used to improve the care of patients
within health care systems.
6. Apply knowledge of the established evidence to
streamline the transition of care process and ultimately
improve individual patient and health care scenarios.
7. Develop an individualized plan to improve the transition of care process in multiple settings across the health
care continuum with a focus on standardizing care.

Introduction
Transitional care refers to the safe and timely transfer
of a patient between health care settings or health care
practitioners. A position statement from the American

Baseline Review Resources

The goal of PSAP is to provide only the most recent (35 years) information on topics. Chapters do not provide an
overall review. Suggested resources for background information on this topic include:
Coleman EA, Boult CE. Improving the quality of transitional care for persons with complex care needs. J Am
Geriatr Soc 2003;51:5567.
Naylor MD, Aiken LH, Kurtzman ET, Olds DM, Hirschman KB. The importance of transitional care in
achieving health reform. Health Aff 2011;4:74654.
Greenwald JL, Halasyamani L, Greene J, LaCivita C, Benjamin B, Reid W, et al. Making inpatient medication
reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps. J Hosp Med 2010;4:47785.

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multidisciplinary care team and care coordinator are

essential both in the inpatient and outpatient settings as
patients transition from one to the other.
There is potentially a tremendous benefit to improving transitional care, both from a patient and societal
perspective. Poorly executed transitional care can be
injurious to the patient and is costly. Medicare claims
data from 2004 reveal a 30-day readmission rate of
19.6%, with only 10% of the readmissions considered
planned (e.g., for alternate knee arthroplasty). Planned
readmissions can be either related to the index admission (e.g., a patient found to have an arrhythmia during hospitalization is discharged for several weeks of
outpatient anticoagulation before returning for ablation) or unrelated (e.g., a patient admitted for community-acquired pneumonia is found to have an oncologic
process and is scheduled to return later for resection).
Spending associated with the unplanned hospital readmissions in this cohort of Medicare beneficiaries was
$17.4 billion in 2004.
Similarly, Medicare data from 2007 showed that
17.6% of hospital readmissions took place within 30
days of discharge; the cost of these readmissions was
$15 billion. Although some of these readmissions were
either planned or unavoidable, most were preventable
and occurred because of improper care transitions from
hospital to home or other settings. The Congressional Budget Office estimates that preventing avoidable
hospital readmissions among Medicare beneficiaries
would reduce health care spending by $7.1 billion over a
10-year period.

Abbreviations in This Chapter

ADE
AHRQ

Adverse drug event

Agency for Healthcare Research
and Quality
B-PREPARED Brief-PREPARED survey
instrument
PCP
Primary care provider
QoL
Quality of life
to appropriately care for themselves, which can hinder effective patient transitions. Another obstacle for
patients in the midst of care transitions can be their
inability to recognize and appropriately respond to the
warning signs that arise when their condition worsens
or they acutely decompensate.
This chapter provides a comprehensive review of
transitional care. Pharmacists have the unique opportunity to positively affect care transitions; however, to
effectively do so, they require a thorough understanding of the process, areas for improvement, and local and
national initiatives related to transitional care.
Epidemiology
The prevalence of care transitions varies by setting
and patient population. The National Hospital Discharge Survey reported 34.4 million hospital discharges
during 2007, 12.8 million of which occurred in those 65
years and older. The survey notes that although people 65 years and older composed only 13% of the general population, this same cohort accounted for almost
40% of all hospital discharges during 2007. Because this
older population experiences a substantial number of
resultant care transitions, one study characterized patterns of transition during the 30-day posthospital discharge period in a cohort of Medicare beneficiaries. The
investigators found that 60% of the care transitions were
limited to a single transfer, 18% involved two transfers,
9% involved three transfers, and 4% involved four or
more transfers; the remaining 9% resulted in death.
In Medicare beneficiaries, heart failure is most often
associated with readmissions. In 2009, the 30-day readmission rate for patients with heart failure was almost
27% compared with 20% for all other conditions. Data
from 2003 in a similar population of Medicare beneficiaries with heart failure showed a 1.27- to 8.75-fold
increased risk of hospitalization compared with beneficiaries without heart failure. Of the 30-day readmissions for heart failure, around 50% were considered avoidable. Strategies suggested to prevent these
avoidable readmissions include: timely follow-up with
the patients primary care provider (PCP) after hospital discharge, use of a multidisciplinary care team, and
involvement and payment of a care coordinator. The
Transitions of Care

Domains of Transfer: Destination,

Information, and Education
Transitional care literature describes three domains
of transfer: destination, information, and education.
Destination refers to the place where the patient is ultimately transferred. The destination can be intra-institutional, inter-institutional, or between an institution
and home (with or without home health care services).
Appropriate destination determination should include
consideration of the patients goals for medical and
functional recovery, the risk-benefit ratio of transferring the patient to a new location, and the appropriateness of the new location for the patient. Considerations
for the appropriateness of location include the acuity of
care required by the patient, the frequency of laboratory
monitoring, and the degree to which the patient is able
to perform activities of daily living.
The information domain encompasses the information provided by the health care providers at one setting to those at the transfer destination. Typical information transferred includes a discharge summary, discharge instructions, current drug list, follow-up studies, and follow-up appointments. It is essential that this
information be current and complete and that it include
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antibiotics, analgesics, and cardiovascular drugs. The risk

of ADEs increases with the number of drugs prescribed
upon discharge. In addition to drug-related adverse events,
patients can be injured by neglected laboratory work or
studies. A cross-sectional study of more than 2600 patient
discharges found that almost 40% had test results pending
at the time of discharge, and 10% required an action that
was not performed.

pertinent instructions (e.g., warning signs to watch for,

when to seek urgent care).
Education is the third transfer domain. Transitional
care education should involve the patient, the health care
team, and the patients family members or caregivers.
Educational topics that are important to review are the
patients drug list, the indication for each drug, the potential adverse effects of the drugs, functional prognoses,
and instructions for activity, eating, and bathing. Patient
education and any educational materials provided should
be communicated in a language and at a reading level that
are easily comprehended by the patient. Education is
important for empowering patients to take responsibility
for their health care. For patients to be able to advocate
for themselves, they must have proper education about
their drugs and medical conditions.

Inpatient Transfers
Hospitalized patients may be transferred between
services within the institution. Examples of intra-institutional transfers are (1) transfer from the intensive care
unit to the medical ward, (2) transfer from the labor and
delivery ward to the postpartum ward, and (3) transfer
from surgery to the surgical intensive care unit. These
types of transfers are important to consider; however,
current data describing the characteristics and frequency of these types of transfer are limited, as are the
data on how to improve them.

Types of Transfer
Inpatient to Outpatient
As previously mentioned, there were more than 34
million hospital discharges in the United States in 2007;
six diagnoses accounted for almost 40% of these discharges: child delivery (4.1 million), heart disease (4.0
million), psychoses (1.7 million), malignant neoplasms
(1.2 million), pneumonia (1.1 million), and fractures
(1.0 million).
Rates of postdischarge adverse events during the hospital-to-home transition vary by study but range from
2.9% to 19%. These events fall into three categories: (1)
hospital care system characteristics, (2) patient characteristics, or (3) clinician characteristics. The major
characteristics of the hospital care system include communication from the institution to the patients PCP
(e.g., discharge summary), provision of patient education, arrangement of home health services, and provision of medication reconciliation. Patient characteristics that affect the incidence of adverse effects include,
but are not limited to, literacy level (general and healthrelated), language barriers, substance abuse issues, drug
adherence, financial issues, cognition, age, and followup visit adherence. Finally, clinician-related issues that
affect postdischarge events include timeliness of laboratory or test orders, resolution of abnormal laboratory or
test results, appropriateness of patient drug therapy, and
completeness of communication between providers.
Because of the many potential postdischarge adverse
event issues, several studies have reevaluated and redesigned hospital discharge processes; these studies are
discussed later in the chapter.
Of the adverse events that occur after hospital discharge,
adverse drug events (ADEs) account for almost two-thirds.
One study of 400 patients found that 19% experienced
an adverse event within 3 weeks of hospital discharge,
and 66% of the adverse events were drug-related. Drugs
often implicated include corticosteroids, anticoagulants,

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Outpatient to Inpatient
Patients can be transitioned from the outpatient to
the inpatient setting by a variety of mechanisms, but a
common pathway is admission to the hospital from the
emergency department. In 2007, 14.6 million emergency department visits resulted in hospital admissions.
However, there is a paucity of data related to outpatient
to inpatient transfers.
Investigators retrospectively examined a cohort,
composed of a 5% sample of Medicare beneficiaries, and
the continuity of care received during a hospital admission. The cohort had almost 5.5 million hospital admissions between 1996 and 2006. The investigators found
that continuity of care decreased from 1996 to 2006; in
1996, 50.5% of patients admitted to the hospital were
cared for during their hospitalization by someone they
had seen in the past year (e.g., their PCP). In 2006, only
39.8% received this same continuity of care. The difference in the rates of continuity of care between 1996 and
2006 was statistically significant. One of the explanations for this decrease is the increase in hospitalist care,
which may have benefits of improved efficiency and
maintenance of communication with the patients PCP.
So although the patient may not be seeing his or her
PCP while hospitalized, often the hospitalist is in direct
communication with this care provider.
Patient transfer from the outpatient to the inpatient
setting generates many issues, including discontinuation
of or changes to home drugs or drug doses, patient disorientation because of a new setting other than home,
and potential gaps in care related to incomplete information. Often, when patients are admitted to the hospital, many days elapse before the hospital receives records
from the patients outpatient clinic or site of service.
During this lag time, duplication of laboratory values or
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Many medication changes are made during a hospitalization because of institutional formulary requirements
or the patients acute needs. It is likely that the medication changes made were appropriate or of minor impact
during the short length of stay (median, 6 days) and that
the adverse effects were delayed until the patient had
been transitioned from the inpatient setting, allowing
the adverse effects time to manifest.

incomplete medication reconciliation may occur. If a

patient is admitted to a hospital within the same health
system as where the patient receives outpatient care,
continuity of care during the inpatient stay (and upon
hospital discharge) is theoretically more likely to occur.
Inpatient and Long-term Care Facilities
Transitions from inpatient settings to long-term care
facilities occur often for patients older than 65 years.
Data from 1992 through 1994 showed that of 15.1 million transitions of elderly patients, more than one-third
(36.4%) were from a short-term hospital to a long-term
care or paid home health care setting. In this patient
cohort, five health conditions accounted for more than
75% of potentially avoidable hospital stays: heart failure,
pneumonia, kidney or urinary tract infection, volume
depletion (including dehydration), and angina. Patients
with these conditions should be targeted because they
represent a population at high risk of transitional care
problems. Several of these high-risk conditions (heart
failure, angina, and pneumonia) are also common reasons for hospital admissions in the adult population;
therefore, this focus need not be limited to the elderly.
If these types of hospital stays can be avoided, then the
issues that arise during the transfer from the hospital
setting to a long-term care facility can also be avoided.
Data have shown that more than 50% of medication discrepancies that occur during transitions
from the inpatient setting to skilled nursing facilities
occur with cardiovascular drugs, opioid analgesics,
neuropsychiatric agents, antihyperglycemics, antibiotics, and anticoagulants. Of interest, these drug classes
align well with the five medical conditions most likely
to lead to an avoidable hospital stay (e.g., heart failure
and angina = cardiovascular agents, pneumonia and
urinary tract infection = antibiotics). These drug classes
include several that are high in risk, including insulin,
opioid or narcotic analgesics, and anticoagulant drugs.
Although a medication discrepancy with any class of
drugs is unfortunate, discrepancies resulting in overdoses, underdoses, or omitted doses in these high-risk
classes can be especially harmful to patients.
In another study of transitions, data were collected
on medication changes made during patient admissions
from four nursing homes to two academic hospitals.
During 122 admissions of 87 patients, there was an average of 3.1 medication changes as patients transitioned
from the nursing home to the hospital and 1.4 medication changes as patients transitioned from the hospital back to the nursing home. The physician investigators reviewed 71 bidirectional transfers and found
that ADEs occurred in 20% of these transfers. Of interest, whereas most implicated medication changes were
made during hospitalization, the majority of ADEs
occurred once the patient returned to the nursing home
(mean time to ADE from medication change, 14 days).

Transitions of Care

Screening and Preventing

Negative Outcomes
Screening
Appropriate screening and risk assessments are
essential to perform on every patient as they transition
between health care settings or health care providers.
Several studies have determined risk factors that predict hospital readmissions (Table 2-1). Although these
studies examined different patient populations, common predictors of readmission include the number and
type of comorbidities and the number of previous hospital admissions. Not all of the risk factors identified in
these studies are modifiable, but those that are modifiable present opportunities for intervention.
The Better Outcomes for Older adults through Safe
Transitions (BOOST) Care Transitions Resource Room
has a risk assessment tool called the 8Ps. This tool identifies problem drugs (e.g., warfarin), psychological issues
(e.g., depression), principal diagnosis (e.g., stroke),
polypharmacy (five or more drugs, including scheduled and as needed), poor health literacy, inadequate
patient support, prior hospitalizations, and palliative
care as areas to identify and assess as patients transition
from one health care setting to another. All risk factors
identified and assessed with this tool are key issues that
should be communicated between health care providers
as patients are transitioned. Although the 8Ps tool was
created by providers of health care for older adults, it has
many features that can be used to assess risk in other age
groups. This tool and others like it are useful to assess risk
and potentially avoid unnecessary readmissions; however, they are not yet validated in the literature.
Preventing Readmissions
In addition to screening for and targeting modifiable
risk factors, two main factors can be targeted to prevent readmissions as patients are transferred from the
acute or inpatient setting: (1) streamlined transition
processes and (2) effective communication between the
health care provider and the patient.
Streamlined Process to Transition
from Health Care Settings
Information on streamlining transition processes
is available from several organizations. The Care
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Table 2-1. Study Findings on Predictors of Readmission

Authors,
year
Naylor,
2000
Smith et al,
2000
Coleman et
al, 2004

Hasan et al,
2009

No. of
Patients Predictors
272
Self-health rating, emergency vs. elective admission, number of
comorbidities, number of previous hospitalizations, number of
prescribed daily drugs, functional status
Veterans Health
1378
Number of hospitalizations and ED visits in the previous 6 months, elevated
Administration
BUN, lower mental health function, COPD, increased satisfaction with
patients with DM,
access to emergency care
COPD, or HF
Medicare
1404
Medicaid recipient, heart disease, previous stroke, diabetes, number of
beneficiaries
previous hospitalizations, visual impairment, age + Medicaid, diabetes +
other comorbidities, functional impairment + comorbidities, impaired
ADLs + comorbidities, stroke + low self-rated health, cancer + low selfrated health, heart disease + visual impairment, and heart disease + cancer
General medicine
10,946 Insurance status, marital status, having a regular physician, Charlson
comorbidity index, SF12 physical component score, > 1 admission
patients
within the past year, current length of stay > 2 days

Setting/Population
Elderly

ADLs = activities of daily living; BUN = blood urea nitrogen; COPD = chronic obstructive pulmonary disease; DM = diabetes mellitus;
ED = emergency department; HF = heart failure; SF12 = 12-Item Short Form Health Survey.

caregivers obtained and provided to patient. The tools do

not result in a score but rather offer a checklist of interventions to prevent problematic care transitions.

Transitions Intervention provides examples for a transition survival kit that patients and providers can use
to ensure that all information is transferred effectively.
These essential elements should be part of every transition and include a personal health record, discharge
preparation checklist, drug list, scheduled follow-up
appointments, education about the patients health conditions, and discussion of health goals.
In addition to the 8Ps tool provided by the BOOST
Care Transitions Resource Room, there is a Tool for
Addressing Risk: A Geriatric Evaluation for Transitions
(TARGET)a multidisciplinary tool that can be used
and adapted for streamlining care transitions. The TARGET tool uses the 8Ps tool, a risk-specific intervention
plan based on the 8Ps risk assessment summary, a universal checklist, and a general assessment of preparedness (GAP) to assess the readiness of patients and their
caregivers to transition between settings. The GAP tool
lists the following criteria to evaluate before discharge:
functional status evaluation completed, cognitive status assessed, ability to obtain drugs confirmed, responsible party for ensuring medication adherence identified and prepared (if not patient), home prepared for
patients arrival (e.g., medical equipment, safety evaluation, food), financial resources for care needs assessed,
transportation to home arranged, access to home (e.g.,
keys) ensured, and support circle for patient identified.
The GAP tool lists the following as discharge criteria:
comprehension of diagnosis, treatment, prognosis, follow-up, and postdischarge warning signs and symptoms
confirmed with teach-back; transportation to initial
follow-up arranged; and contact information for home

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Communication Between Health Care

Providers and the Patient
The tools previously mentioned facilitate written
and verbal communication between health care providers and patients during health care transitions. Effective communication between health care providers and
patients improves patient health outcomes. A recent
review concluded that provider-patient communication
is a positive interaction most of the time. Effective communication not only positively affects patients emotional health, it also positively affects symptom resolution, functional and physiologic status, and pain control.
Communication does not have to be limited to the
health care provider and patient; use of a transition coach
for ongoing communication is effective and important
for improving patient outcomes. A transition coach is
a health care practitioner (e.g., an advanced practice
nurse) who performs medication reviews and reconciliation, helps patients communicate their needs and concerns to all of their health care providers, and supports
and encourages patients to be active participants in their
own health care.
A recent study was designed around four pillars of
effective transitional care: (1) assistance with drug selfmanagement, (2) a patient-centered medical record
owned and maintained by the patient, (3) timely followup with primary and/or specialty care, and (4) a list of
warning signs indicative of a worsening or new, acute
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condition. A transition coach assisted the intervention

group during the transition. The transition coach was
essential for reviewing drug lists and correcting discrepancies, educating the patient on posthospital follow-up
and the red flags to be aware of and how to respond to
them, and following up with the patient by telephone
three times during the 28-day postdischarge period. The
study results showed significantly decreased readmission rates at 90 and 180 days in the intervention group
compared with the control group. The transition coach
provided a means of communication to the patient that
went beyond communication at the time of transition,
highlighting the importance of ongoing communication
as patients navigate care transitions.

Goal 03.06.01, which states the goal of maintaining and

communicating accurate patient drug information. The
key aspect of the National Patient Safety Goal is that
many health care settings (e.g., ambulatory care, behavioral health, critical access hospitals, home care, hospitals, long-term care, office-based surgery centers) have
the same goal of improving patient safety. Because the
transition of care process crosses several health care settings, it is essential to use national standards and goals
to drive this process with a focus on improved care for
all patients. Many systems across the country perform
these activities through a variety of processes; therefore,
the study and publication of best practices and procedures related to medication reconciliation are needed.
Open Communication Processes
and Modes for Improvement
Health care provider communication at all points of
patient care transition is one of the main deficiencies
in the transition process. Investigators have characterized the literature in this are with a focus on the transition of patients from the hospital setting back to care
by their PCP. Direct communication between hospital
health care providers and PCPs occurred infrequently
(3% to 20%). In addition, PCP access to a discharge
summary was low (12% to 34%) at postdischarge follow-up with the patient. Of even greater concern was
the lack of important information in the discharge summary, when available for review (e.g., diagnostic tests,
discharge drugs, follow-up plans). On the basis of the
reported numbers in the medical literature, all of these
potential deficiencies in communication at the time of
discharge are common and they put patients at risk of
a variety of adverse effects. Improved communication
processes across all health care settings are essential for
the safe and optimal care of patients.

Performance Measurements in
the Transition of Care Process
While there are many standards being established to
improve transition of care processes, there is a general
lack of standard assessment and interpretation of measurements to evaluate the outcomes associated with
transitions of care. For example, the Joint Commission
has set standards for medication reconciliation. The
Agency for Healthcare Research and Quality (AHRQ )
has set a standard for information transmission from an
inpatient setting to the patients PCP within 24 hours of
discharge. Finally, the Centers for Medicare & Medicaid
Services (CMS) has directed the network of 53 Quality Improvement Organizations (QIOs) to focus on the
transition of care process in every state in the United
States. The primary goal of the QIOs is to reduce hospital readmissions within 30 days of discharge and create a
model for improving care transitions.
In studies evaluating the transition of care process,
several measures have been assessed, including reduced
readmission rates (e.g., within 30 days) and improvements in medication reconciliation, health care use rates,
and quality-of-life (QoL) metrics. However, a lack of
consensus guidelines on standardized measures makes
it difficult to apply these to an individual health care setting. There is a need for national organizations to set specific, validated measurements as the gold standard to
streamline the transition of care process and more easily
track and compare health care systems across the nation.

System Resource Assessments

to Improve Transitions
When targeting a system improvement in the transition of care process, the available resources to provide this transitional care must be assessed. In addition, depending on the level of care a system provides
(e.g., acute, chronic), there must be a feasibility analysis of what already works, what to change first, and what
the short- and long-term goals should be for this process. National goals (e.g., those set by AHRQ and the
Joint Commission) are a good resource for developing
standard processes, providing focus interventions, and
improving the care of patients in all health care settings.

Targeted Approach to Improving

the Transition of Care
Focused Health System Targets
Many health systems across the nation have developed, or are developing, standard transitional care targets. In emphasizing medication reconciliation as one
of the key components in the transition of care process,
the Joint Commission created National Patient Safety
Transitions of Care

Goal Development and Process for Review

The process of goal development should involve the
creation of goals that are supported by the medical literature and national organizations (e.g., AHRQ ). In addition, each health system must determine the feasibility
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Interventions Focused on Patient Education

Patient education is an essential component of the
transition of care process in all health-system settings.
Literature supports patient education interventions and
assessment, especially before discharge from the hospital setting. One instrument, identified by the acronym PREPARED, evaluates the following: Prescriptions, Readiness to reenter the community, Education,
Placement, Assurance of safety, Realistic expectations,
Empowerment, and Direction to appropriate services.
Because its length was a barrier to its use, the authors
assessed patients by a Brief-PREPARED (B-PREPARED) survey instrument to determine each patients
preparedness for hospital discharge on the basis of individual perspective and education.
The B-PREPARED instrument assessed 460 patients
through telephone interviews 1 week after hospital discharge. Specifically, the instrument was able to measure
patient perceptions of the quality and benefit of the discharge planning process. High scores reflect high preparedness as it pertains to self-care information, equipment/services, and confidence. The higher the B-PREPARED score, the more likely the patient was to feel
comfortable managing at home. Higher scores also predicted a lower likelihood of emergency department visits after hospital discharge. This study validated one possible tool to assess patient educational level and potentially determine which patients might need more or less
education before discharge from the hospital.

of adopting each goal. An evaluation of the baseline

processes and current metrics as they pertain to transition of care concerns (e.g., hospital readmission rates,
patient education processes) should be at the forefront
of the discussion. Involving an interdisciplinary team
in the goal development and review process is essential. This allows input from representatives of the health
care team who are or potentially could be involved in
improving the transition of care process in individual
health care systems.

Effective Transition of
Care Interventions
Studies have shown numerous barriers (e.g., financial, logistical) to the provision of transitional care
focused activities related to both qualitative and quantitative measures. Most of these activities target the transition of care process from inpatient to outpatient settings, but they can be applied to a variety of other transitional settings. Several interventions focused on these
measures have been evaluated and divided into four primary areas: medication reconciliation, patient education, hospital readmission, and QoL. Table 2-2 lists the
major trials, interventions, and outcomes.
Interventions Focused on Medication Reconciliation
Medication reconciliation is a key focus for patient
transitioning from any care setting, especially in the
chronic management of patients with many care providers. Many investigators have looked at various modalities to perform medication reconciliation and the resulting impact on patient care. Pharmacist involvement in
medication reconciliation is a key part of transitions of
care.
A pharmacist intervention study evaluated the role of
pharmacist medication reconciliation and counseling in
the prevention of ADEs after hospitalization. A pharmacist intervention arm was compared with a usual care
arm in the study. The pharmacist intervention involved
medication reconciliation on the day of discharge,
including drug education (e.g., adherence, ADEs, directions for use), and telephone follow-up with the patients
35 days postdischarge to re-review the drug education
and verify any discrepancies from the day of discharge.
The primary outcome was the presence of preventable ADEs in patients 30 days after hospital discharge.
Preventable ADEs were detected in 11% of the usual
care patients and in 1% of the pharmacist intervention patients. Overall, there was no difference between
groups with respect to total ADEs or total health care
resource use. This is just one study of many to highlight
the key role the pharmacist plays in the medication reconciliation process at the time of hospital discharge.
PSAP-VII Science and Practice of Pharmacotherapy

Interventions Focused on Hospital Readmission

Several interventions that focused on a reduction in
readmission rates after hospital discharge highlight the
importance of the transition of care process. As previously mentioned, one of the largest studies to focus on
readmission randomized 750 elderly patients (older
than 65 years) who had been admitted to the hospital to
receive a transition intervention (i.e., transition coach)
or usual care. The transition intervention patients had
30-day and 90-day rehospitalization rates lower than
the usual care patients. In addition, the mean hospital
costs at 180 days were significantly lower in the transition intervention patients than in the usual care group.
The findings from this study reinforce that encouraging elderly patients and caregivers to take a more active
role in their care transitions can result in a lower risk of
rehospitalization in the first 90 days postdischarge.
Interventions Focused on QoL
Several QoL surveys and scales have assessed effects
related to the transitional care process. An Australian study focused its transition of care intervention
on the elderly (older than 65 years), who are generally
at a higher risk of readmission to the hospital than the
adult population. The intervention included a nursing
and physiotherapy assessment and an individualized
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Table 2-2. Trials Evaluating Interventions Focused on Transitions of Care

RCT
(duration)
Population (n)
Coleman et al, Age > 65 admitted
2006
to general medicine
(6 mo)
service (750)

Crotty et al,
2005
(2 mo)

Elderly (mean age = 82)

hospitalized patients
awaiting transfer to
LTCF (110)

Jack et al, 2009 Age > 18 admitted

(1 mo)
to general medicine
service (749)

Jerant et al,
2001
(12 mo)

Age > 40 admitted for

HF (37)

Kasper et al,
2002
(6 mo)

Admitted for NYHA

class III/IV HF at high
risk of readmission
(200)
Kimmelstiel et Admitted for HF (200)
al, 2004
(3 mo)
Koehler et al,
2009
(2 mo)

Age > 70 admitted

for medical reason
and at high risk of
readmission (41)

Koelling et al,
2005
(6 mo)
Krumholz et
al, 2002
(12 mo)

Admitted for HF (223)

Naylor et al,
1999
(6 mo)

Age > 65 admitted for

medical or surgical
reason (363)

Age > 50 admitted for

HF (88)

Intervention
Outcome
Patients were given a personal health record, 30-day readmission rates were 8.3% and
had a follow-up with a transition coach
11.9% in the intervention and control
(APN) through home visits and telephone groups (p=0.048)
follow-up, and had a follow-up with their 90-day readmission rates were 16.7%
primary physician posthospital discharge
and 22.5% in the intervention and
control groups (p=0.04)
Medication management by a pharmacist MAI in intervention vs. control group
transition coordinator
(2.5 vs. 6.5; p=0.007)
0.38 RRR (95% CI, 0.150.99) in the
intervention vs. control group for
rehospitalization or ED visit
A nurse discharge advocate set up follow-up 0.695 RRR (95% CI, 0.5150.937) in
appointments, provided patient education, the intervention vs. control group for
and completed medication reconciliation. hospitalization or ED visit at 30 days
Clinical pharmacist conducted telephone
follow-up with patient 24 days
postdischarge
Home telecare delivery through two-way Mean readmission costs at 6 mo in the
video conferencing or nurse telephone
telecare, nurse telephone follow-up,
follow-up or usual care
and usual care groups were $5850,
$7320, and $44,479, respectively
(p=0.26)
Involved a telephone nurse coordinator,
6-mo composite of HF readmission
HF nurse, HF cardiologist, and the
death were 49% and 73% in the
patients primary physician managing the intervention and control groups
patients care
(p=0.09)
Home visit by HF nurse within 3 days of 0.48 RR (p=0.027) in the intervention
hospital discharge and included patient
vs. control group for HF hospital
education, weekly or biweekly telephone readmission at 90 days
follow-up. Nurses were available to
patients by phone 24 hr/day
Medication counseling and reconciliation 30-day readmission rates were 10.0%
by a pharmacist, patient education and
and 38.1% in the intervention and
discharge planning by care coordinator,
control groups (p=0.04)
and telephone follow-up within 24 hours No difference in readmission rates at 60
postdischarge and continued for up to
days
1 week
Nurse educator met with patients for a
0.65 RR (95% CI, 0.450.93) in the
one-on-one HF education session for 1
intervention vs. control group for
hr before hospital discharge
rehospitalization or death at 6 mo
Cardiac nurse assessment of patient
0.69 RR (95% CI, 0.520.92) in the
baseline education, 1 hr of face-tointervention vs. control group for
face teaching, 2 wk postdischarge, and
hospital readmission or death at 1 year
telephone follow-up weekly with patient 0.56 adjusted RR (95% CI, 0.320.96)
in the intervention vs. control group
for hospital readmission at 1 year
APN discharge planning and home
17% in patients with 1 readmission
follow-up
in intervention vs. control group
(p<0.01)
8% in patients with many readmissions
in intervention vs. control group
(p<0.01)
(Continued on next page)

Transitions of Care

110

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Table 2-2. Trials Evaluating Interventions Focused on Transitions of Care (Continued)

RCT
(duration)
Naylor et al,
2004
(12 mo)
Rich et al,
1995
(3 mo)

Riegal et al,
2002
(6 mo)

Schnipper et
al, 2006
(1 mo)
Schnipper et
al, 2009
(2 mo)

Population (n)
Age > 65 admitted for
HF (239)

Intervention
3-mo APN discharge planning and home
follow-up

Outcome
46% readmission rate in intervention
vs. control group (p=0.047)
total mean costs per patient/year in
intervention vs. control group ($7636
vs. $12,481; p<0.002)
Age > 70 admitted for Nurse-directed intervention including
90-day survival without readmission
HF (282)
cardiologist care, social services support, rates were 64% and 54% in the
home care services, and telephone
intervention and control groups
follow-up
(p=0.09)
HF readmission 56% in patients in
the intervention vs. control group
(p=0.04)
Admitted for HF (358) Standardized telephonic case
3-mo HF readmission rates were 46%
management by a nurse within 5 days of
lower in the intervention vs. control
hospital discharge and then periodically
group (p=0.03)
for 6 mo
6-mo HF readmission rates were 48%
lower in the intervention vs. control
group (p=0.01)
Admitted to general
Pharmacist counseling at discharge and
0.10 unadjusted OR (95% CI,
medicine service
telephone follow-up within 35 days
0.0130.86) for PADEs at 30 days
(178)
postdischarge in intervention vs.
control group
Admitted to general
Use of a computerized medication
0.72 ARR (95% CI, 0.520.99) for
medicine service
reconciliation tool
PADEs in intervention vs. control
(322)
group

ADE = adverse drug event; APN = advanced practice nurse; ARR = adjusted relative risk; CI = confidence interval; ED = emergency
department; HF = heart failure; hr = hour(s); LTCF = long-term care facility; MAI = medication appropriate index; mo = month; NYHA
= New York Heart Association; OR = odds ratio; PADE = potential adverse drug event; RCT = randomized controlled trial; RR = relative
risk; RRR = relative risk reduction; wk = week.

National Quality Improvements

Related to Transitions of Care

program of exercise and nursing home visits or telephone follow-up for patients up to 24 weeks after hospital discharge. Patient QoL was assessed using the Medical Outcomes Study 12-item Short Form Survey at baseline and at 4, 12, and 24 weeks after hospital discharge.
The survey scores individuals on a scale of 0100, with
lower score indicates poorer health-related QoL and the
minimal difference in clinical significance ranging from
5 to 10 points. Responses to the 12-item Short Form
Survey standard form (4-week recall) were scored and
aggregated into Physical Component Summary scores
and Mental Component Summary scores.
A statistically significant improvement was found
between intervention and control group QoL scores
for the physical and mental component summaries.
Improvements were noted in QoL through a complex
intervention including an individual exercise program
and nursing follow-up. Therefore, it is difficult to separate the individual components of the intervention and
determine the driver for improvement in QoL.
PSAP-VII Science and Practice of Pharmacotherapy

Institute of Medicine
In 2003 the Institute of Medicine (IOM) developed a
priority list of 20 key areas for transforming health care.
One of the main priorities was drug management, with
a specific focus on preventing drug errors. This is one
of the main reasons that medication reconciliation has
become a focus in all areas of health care to improve the
transition of patients between settings.
The drive to reduce drug errors has streamlined the
reconciliation process within many health systems,
but medication reconciliation processes remain varied
across the nation. A best practices model for medication reconciliation should be developed in the United
States to standardize this process. Two other areas identified by the IOM were care coordination and self-management/health literacy. These two areas were identified as overlapping all areas of health care delivery.
With a greater effort focused on care coordination and
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optimization of processes in a variety of settings, the

hope is for improved patient transitions and increased
overall patient safety in the United States.

Communication is an essential part in the transition of care process, and pharmacists are well trained to
communicate with patients and other health care providers such that they can serve as a bridge between
various health care providers and settings. As standards
for more specific transitional care quality improvement
are established, the pharmacists role and involvement
in the process will continue to expand. However, health
care systems should continue to stress the importance
of the pharmacists role in this process on a day-to-day
basis and strive to set individualized goals with a focus
on national standards.

U.S. Department of Health and Human Services

The AHRQ and the U.S. Department of Health and
Human Services have developed a national quality measure focused on care transitions. This measure is used to
assess the percentage of patients, regardless of age, discharged from an inpatient facility to home or any other
site of care for whom a transition record was transmitted to the facility or primary physician or other health
care professional designated for follow-up care within
24 hours of discharge. This is assessed using a bundle set
measurement of patients who received medication reconciliation as well as transition record documentation.
The AHRQ has not reported the application and tracking of this measure.

Conclusion
Recent studies continue to support pharmacist
involvement in the transition of care process. The pharmacists role in medication reconciliation is well documented to produce positive effects. Nationally, the
importance of the pharmacists role on the multidisciplinary team as it pertains to transitions of care needs to
be emphasized, as has been done for other patient issues
such as optimization of pharmacotherapy and monitoring. Future studies to evaluate the importance of interventions focused on improving health care transitions
are expected to advance the multidisciplinary approach
to patient safety. Finally, focus must be placed on communication among health care providers and patients,
with a standard process in place to allow performance
measure evaluation.

Transitions of Care Consensus Policy Statement

In 2009, the American College of Physicians, Society of Hospital Medicine, Society of General Internal
Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic
Emergency Medicine developed a consensus policy on
transitions of care. The policy highlights recommended
standards that organizations and health systems should
follow in streamlining the transition of care process.
The key standards include establishing coordinating clinicians, developing care plan/transition records, creating a communication infrastructure, using standard
communication formats, designating transition responsibilities, focusing on timeliness, assessing community
standards, and developing measurement tools. Details
on the development of these standards are available in
the specific policy statement.

Annotated Bibliography
1.

Role of the Pharmacist

Investigators assessed patients from four nursing

homes in New York City who had a recent hospitalization. Medical records from the nursing homes and the
hospitals were reviewed and evaluated specifically for
drug discrepancies. Drugs were matched and compared
for dose, route, and frequency. All patient charts were
reviewed for ADEs. In 122 patient admissions, the mean
number of drugs altered was three when going from the
nursing home to the hospital; the mean number was a
little more than one when going from the hospital to
the nursing home. The most common change noted
was drug discontinuation. In the 71 bidirectional transfers, ADEs caused by medication changes occurred
during 14 (20%). The overall risk of ADE per drug alteration (n=320) was 4.4% (95% confidence interval [CI],
2.5% to 7.4%). The authors concluded that medication
changes are common during transfer from nursing
homes to hospitals and are a possible cause of ADEs.

Several studies have assessed the impact of adding or

involving a pharmacist in the transition of care process.
In many of the studies, the pharmacist has been one of
the health care providers in the intervention because
most interventions target a multidisciplinary approach.
As previously discussed, for the past 510 years, there
has been a major focus on improving patient transitions
from both a qualitative and quantitative perspective. As
health care reform becomes a reality, pharmacists will
have the opportunity to drive change through medication therapy management, involvement in the medical
home model, and efforts to improve the transition of
care process. Both the inpatient and outpatient pharmacist (community and ambulatory care) should join the
work of forging a pathway for pharmacy as it pertains to
health care reform.
Transitions of Care

Boockvar K, Fishman E, Kyriacou CK, Monias A, Gavi

S, Cortes T. Adverse drug events due to discontinuations in drug use and dosage changes in patients transferred between acute and long-term care facilities. Arch
Intern Med 2004;164:54550.

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2. Braunstein JB, Anderson GF, Gerstenblith G, Weller

W, Niefeld M, Herbert R, et al. Noncardiac comorbidity increases preventable hospitalizations and mortality
among Medicare beneficiaries with chronic heart failure. J Am Coll Cardiol 2003;42:122633.

were estimated to be $295,594, which more than outweighs the cost of the coach. This trial justified the role
of a transition of care coach to improve overall health
care costs and readmission rates in an elderly population after a general medicine admission.

This cross-sectional study analyzed preventable hospitalizations and all-cause mortality in a nationally
representative random cohort of U.S. Medicare beneficiaries 65 years and older with chronic heart failure
and comorbidities. The Clinical Classification System,
developed by AHRQ , was used to identify the individuals with congestive heart failure and chronic comorbidities. The investigators found that in subjects with congestive heart failure alone, the mean probability of hospitalization was 35%. For subjects with congestive heart
failure and comorbidities, the probability increased
to 72% for those with 5 comorbidities and 94% for 10
or more comorbidities. Chronic lower respiratory disease and kidney failure were the comorbidities associated with the highest mortality risk (relative risk [RR]
2.34; 95% CI, 2.272.41 and RR 1.65; 95% CI, 1.58
1.73, respectively). The investigators concluded that
although cardiology-specific interventions are necessary in the congestive heart failure population, attention should also be paid to the management of other
comorbidities because noncardiac comorbidities can
also influence hospitalization and all-cause mortality.

4.

The Medicare Current Benefit Survey was used to

describe patterns of posthospital care transitions in
beneficiaries 65 years and older between 1997 and
1998. The study evaluated the 30-day posthospital discharge period in patients. Patients were declared to have
uncomplicated or complicated posthospital care, and
indices (e.g., the Charlson index) were used to identify
whether patients were at risk of complicated transitions.
Forty-six distinct types of care patterns were observed
during the 30 days after hospital discharge. Most of
the patients had one (61.2%) or two (17.9%) transfers
after hospitalization. Overall, between 13.4% and 25%
of posthospital care patterns in the 1998 sample were
classified as complicated. The authors concluded that
transitions after hospitalization were common among
Medicare beneficiaries. Important implications related
to patient safety and cost-avoidance need to be assessed
in relation to the complexity of patient transitions after
hospital discharge.

3. Coleman EA, Parry C, Chalmers S, Min SJ. The care

transitions intervention: results of a randomized controlled trial. Arch Intern Med 2006;166:18228.

5.

The study investigators conducted a randomized controlled trial of a transition of care intervention including the use of a transition coach. They enrolled 750
patients 65 years or older with one of 11 specific conditions (e.g., coronary artery disease, diabetes mellitus)
resulting in a recent hospitalization. The intervention
group (n=379) received assistance with drug self-management, a patient-centered record owned and maintained by the patient to facilitate cross-site information transfer, timely follow-up with primary or specialty
care, a list of warning signs indicative of worsening condition, and instructions on how to respond to them. The
intervention was facilitated through each patients personal health record and by a transition coach who followed up with the patient through a series of visits and
telephone calls. The control group (n=379) received
usual care, including traditional discharge instructions
from the hospital, but did not receive any of the intensive discharge education or telephone follow-up. The
primary outcome measure was the rate of readmission
to the hospital at 30, 90, and 180 days postdischarge
from the index hospitalization. The intervention arm
had lower 30-day (8.3 vs. 11.9; p=0.048) and 90-day
(16.7 vs. 22.5; p=0.04) readmission rates than the control arm. Overall, the mean hospital costs per patient
were lower in the intervention arm ($2058) versus the
control arm ($2546) at 180 days after the index hospitalization. The cost of the transitions coach was $74,310
(salary plus expenses), and on the basis of cost extrapolation data, the annual cost savings of using the coach

PSAP-VII Science and Practice of Pharmacotherapy

Coleman EA, Min SJ, Chomiak A, Kramer AM. Posthospital care transitions: patterns, complications, and
risk identification. Health Serv Res 2004;39:144966.

Courtney M, Edwards H, Chang A, Parker A, Finlayson

K, Hamilton K. Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the
effectiveness of a 24 week exercise and telephone follow-up program. J Am Geriatr Soc 2009;57:395402.
A randomized controlled trial of 128 patients at a tertiary metropolitan hospital in Australia evaluated the
effect of an exercise program and in-home follow-up in
elderly patients after a recent hospitalization. Half of the
subjects received an intervention that included nursing
and physiotherapy assessment, individualized exercise
program, a nurse-conducted home visit, and telephone
contact after hospital discharge for 24 weeks. The control group received the routine care, discharge planning, and rehabilitation advice normally provided. The
primary outcomes were health service use (e.g., hospital readmission, emergency department visits, PCP visits) and QoL. In the intervention arm, hospital readmission rates were reduced by half (22% vs. 47% control;
p=0.007); and 25% of the intervention group had emergency visits with their PCP compared with 67% of the
control group (p<0.001). Qualify of life was improved
in the intervention group as well. Early exercise program initiation and hospital follow-up by nurses may
reduce elderly patients readmission rates in the first 6
months after hospital discharge.

6. Forster AJ, Murff HJ, Peterson JF, Ghandi TK, Bates

DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann
Intern Med 2003;138:1617.

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The authors of this article conducted a prospective

cohort study at a tertiary care academic hospital; they
enrolled 400 consecutive patients discharged home
from the general internal medicine service. The main
outcomes measured were adverse events, preventable adverse events, and ameliorable adverse events.
Patients were contacted by telephone for a structured
interview at about 3 weeks after hospital discharge.
Nineteen percent of patients suffered an adverse event
within 3 weeks of hospital discharge; 6% were preventable adverse events, and another 6% were ameliorable
adverse events. Adverse drug events were the most common type of adverse event, occurring two-thirds of the
time, with procedure-related injuries occurring in just
under 20% of the group experiencing adverse events.
Overall, this study showed that many adverse events
in the 3 weeks after hospital discharge are potentially
preventable.

planning process, referred to as the reengineered discharge process. The components include the following.
(1) Educate patients about their diagnoses. (2) Make
appointments for clinician follow-up. (3) Discuss test
results with the patient. (4) Organize postdischarge services. (5) Confirm the drug plan. (6) Reconcile the discharge plan. (7) Review the appropriate steps to take if
a problem arises. (8) Expedite the transmission of the
discharge summary to the patients outpatient physician. (9) Assess the patients understanding of the plan.
(10) Give the patient a written discharge plan. (11) Provide a telephone follow-up in 2 or 3 days postdischarge
to reinforce the plan with the patient. Overall, there
are enough emerging data on transitions of care to substantiate a standardized discharge plan to help decrease
postdischarge adverse events and rehospitalization.
9.

7. Graumlich JF, Novotny NL, Aldag JC. Brief scale

measuring patient preparedness for hospital discharge to home: psychometric properties. J Hosp Med
2008;3:44654.

The authors of this article conducted a prospective, observational cohort study of 10,946 patients discharged home from general medicine services at six academic medical centers. The main outcome assessed was
the 30-day readmission rate, determined by administrative data and postdischarge telephone follow-up.
Patient factors affecting readmission were grouped into
four categories: sociodemographic factors, social support, health condition, and health care use. About 17.5%
of patients were readmitted within 30 days of hospital
discharge. Seven factors emerged as significant predictors of early readmission: insurance status, marital status, having a regular physician, Charlson comorbidity
index, SF-12 physical component score, one or more
admissions within the past year, and current length of
stay more than 2 days. The main conclusion of this study
is that there are many assessable patient characteristics
to predict who is at higher risk of hospital readmission.

Study investigators performed a prospective cohort

study (n=460) using telephone interviews after patients
were discharged from the hospital. The aim of the
study was to describe the psychometric properties of
the B-PREPARED survey instrument to measure preparedness for hospital discharge. The telephone interview at 1-week postdischarge included use of the Satisfaction with Information about Medicines Scale and
the PREPARED instrument. The B-PREPARED scale
was used to evaluate patients perceptions of quality
and outcome of the discharge planning processes. At
1 month, postdischarge patients were called again to
assess whether they had been readmitted since hospital discharge. The B-PREPARED scores range from 0
to 22, with higher scores indicating better preparedness
for discharge. The mean score of 17.3 4.2 (SD) indicates that most patients had a high preparedness for discharge on the basis of receiving maximal points in 9 of
12 categories. Higher B-PREPARED scores appropriately discriminated patients with no worry about managing at home from worriers (p<0.001), and higher
scores predicted patients without emergency department visits after discharge versus those who had visits (p=0.011). Authors concluded that clinicians and
researchers could use B-PREPARED to evaluate discharge interventions focused on patient preparedness
to function after hospital discharge.
8.

10. Jencks SF, Williams MV, Coleman EA. Rehospitalization among patients in the Medicare fee-for-service program. N Engl J Med 2009;360:141828.
The study investigators evaluated the Medicare
claims database from 2003 to 2004 to describe the patterns of rehospitalization and the relationship of rehospitalization to patient demographic characteristics and
hospital characteristics. There are major cost implications to identifying patients with a higher risk of rehospitalization. Twenty percent of the more than 11 million
Medicare beneficiaries were readmitted within 30 days
of hospital discharge; readmissions were both planned
(e.g., chemotherapy) and unplanned (e.g., pneumonia).
One-third of patients were rehospitalized within 90
days, and two-thirds of patients with a chronic medical
condition were rehospitalized or dead within 1 year of
the index hospitalization. Of major significance was the
finding that one-half of the patients readmitted within
30 days did not see their PCP after hospital discharge.
This finding has elucidated the need for a focused effort
to increase follow-up with PCPs to improve transitions

Greenwald JL, Denham CR, Jack BW. The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process. J Patient Saf
2007;3:97106.
This review article summarizes the key factors
related to improving patient safety after hospital discharge, with a specific focus on identifying modifiable
components of the discharge process related to adverse
events and rehospitalization. The authors determined
11 discrete components to the streamlined discharge

Transitions of Care

Hasan O, Meltzer DO, Shaykevich SA, Bell CM, Kaboli

PJ, Auerbach AD, et al. Hospital readmission in general medicine patients: a prediction model. J Gen Intern
Med 2009;25:2119.

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PSAP-VII Science and Practice of Pharmacotherapy

after discharge. The authors estimated that the cost of

unplanned rehospitalizations in 2004 in Medicare beneficiaries was more than $17 million.

improved, resulting in lower readmission rates and safer

care for patients.
13. LaMantia MA, Scheunemann AP, Viera AJ, BusbyWhitehead J, Hanson LC. Interventions to improve
care between nursing homes and hospitals: a systemic
review. J Am Geriatr Soc 2010;58:77782.

11. Kripalani S, LeFevre F, Phillips CO, Williams MV,

Basaviah P, Baker DW. Deficits in communication and
information transfer between hospital-based and primary care healthcare providers: implications for patient
safety and continuity of care. JAMA 2007;297:83141.

This is the only systemic review to evaluate the current literature on patient interventions focused on
improving transitions between nursing homes and hospitals. Five studies were included in this review. Two
studies focused on enhancing transmission of advance
directives, two tried to improve communication of drug
lists, and one study evaluated both. Only one of the five
studies was a randomized controlled trial. Study results
indicate that a standardized patient transfer form may
assist with the communication of advance directives
and drug lists and that pharmacist-led reviews of drug
lists may help identify omitted or indicated drugs on
transfer. These studies support standardization in the
transition process between nursing homes and hospitals, but further research is necessary to define target
populations and outcomes measures for high-quality
transitional care.

This review evaluated observational studies (n=55)

focused on communication and information transfer at hospital discharge, as well as controlled studies
(n=18) focused on evaluating efficacy of interventions
to improve information transfer. Evaluation of the studies identified that direct communication between hospital health care providers and PCPs seldom occurred
(less than 20% at discharge). The discharge summary
was available less than one-third of the time when
patients had their initial hospital follow-up with their
PCP and, even at 1 month, was only available about
50% of the time. When the discharge summary was
available, it often lacked important information. In the
studies evaluated, missing information was noted for
diagnostic test results (33% to 63%), treatment or hospital course (7% to 22%), discharge drugs (2% to 40%),
test results pending at discharge (65%), patient or family counseling (90% to 92%), and follow-up plans (2% to
43%). Use of standardized formats to highlight the most
pertinent information improved the perceived quality
of the documents. The authors concluded that communication deficits at hospital discharge are common and
may adversely affect patient care. Focused interventions (e.g., computer-generated summaries, standardized formats) may facilitate improvements in transfer of
patient information to PCPs and make discharge summaries more consistent.

14. Misky GJ, Wald HL, Coleman EA. Post-hospitalization

transitions: examining the effects of timing of primary
care provider follow-up. J Hosp Med 2010;5:3937.
The authors performed a prospective cohort study
of 65 patients admitted to the University of Colorado
Hospital. Patients were assessed after discharge with
telephone follow-up to determine the timing of PCP
follow-up and hospital readmission status. Only 49%
of patients followed up with their PCP within 4 weeks
of hospital discharge. Patients who did not follow up
within 4 weeks of discharge were 10 times as likely to be
readmitted than patients who had timely PCP follow-up
(p=0.04). Patients without insurance had a 50% lower
follow-up rate with their PCP compared with insured
patients, but this did not significantly affect readmission rates. In this study, lack of follow-up with a PCP
within the first month of discharge from the hospital
resulted in a dramatically higher readmission rate. A
focused effort on improving the transitional process for
vulnerable patients at the time of discharge needs further support and evaluation.

12. Kripalani S, Jackson AT, Schnipper JL, Coleman EA.

Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp
Med 2007;2:31423.
This review focuses on the transition of care process when hospitalists are involved in the management
of patients during their hospitalization. Literature has
documented that almost 50% of patients experience a
medical error after hospital discharge, and around 20%
suffer an adverse event, with drug therapy being the
primary culprit. The review describes the challenges
of providing high-quality care at the time of hospital discharge. Key areas identified include the discontinuity between hospitalists and PCPs, changes to the
patients drug regimen, new self-care responsibilities
that may stress available resources, and complex discharge instructions. Areas identified as improving the
transition process include communication improvements between inpatient and outpatient providers,
effective medication reconciliation, patient drug education, medical follow-up, social support systems, and
better physician-patient communication. Through the
implementation and standardization of these principles, the transition of care process can be significantly

PSAP-VII Science and Practice of Pharmacotherapy

15. National Transitions of Care Coalition. Policy Paper:

Improving Transitions of Care. May 2008. Available
at www.ntocc.org/Portals/0/PolicyPaper.pdf. Accessed
June 14, 2011.
This policy paper summarizes the position of the
National Transitions of Care Coalition (NTOCC).
The NTOCC has multidisciplinary representation
from many major health care organizations, including the Academy of Managed Care Pharmacy, American Geriatrics Society, American Society of HealthSystem Pharmacists, and American Society of Consultant Pharmacists. The key steps outlined in this article
include the following: improving provider, patient, and

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from internal medicine as well as family medicine and

pediatrics, governmental agencies (e.g., AHRQ , CMS),
performance measure developers (e.g., National Committee for Quality Assurance) and the American Medical Association Physician Consortium on Performance
Improvement, nurse associations (e.g., Visiting Nurse
Association), pharmacist groups (e.g., American Society of Health-System Pharmacists), and patient groups
such as the Institute for Family-Centered Care. The
TOCCC made recommendations for standards regarding the transitions between inpatient and outpatient settings. The following summarized principles were established: accountability of health care systems, communication by health care providers, timely interchange of
information among health care providers, involvement
of the patient and family members in decision-making,
respect for the care coordination process, and assurance
that all patients and their family/caregivers have a medical home or coordinating clinician. National standards
and standardized metrics should be followed, when
available, for quality improvement and accountability.

caregiver communications; implementing standardized medication reconciliation processes; establishing points of accountability for health care providers
involved in patient transitions; using case managers for
patients; expanding the role of pharmacists in the transition of care process by aligning payment systems with
incentives for improved transitions of care; and developing performance measures to increase better transitions of care. This policy statement includes many
good resources to improve on the key elements previously identified. The members of the NTOCC believe
that addressing these key issues will improve the overall
transition of care process and allow national standard of
carerelated patient health care system transitions.
16. Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA,
Brown BA, Tarvin E, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med 2006;166:56571.
This randomized trial of 178 patients discharged from
the general medicine service of a large teaching hospital
evaluated the role of pharmacist counseling on preventing ADEs after discharge. The patients in the intervention arm received pharmacist discharge counseling and
a telephone follow-up call 35 days after discharge. Specific pharmacist interventions included clarifying drug
regimens; reviewing indications, directions, and potential adverse effects of drugs; screening for barriers to
adherence and for early adverse effects; and providing
patient counseling or physician feedback when appropriate. The control group had standard ward pharmacists review patient drug orders, and nurses performed
drug counseling before patient discharge. The primary outcome of the study was the rate of preventable
ADEs. At 30 days postdischarge, preventable ADEs
were detected in 11% of patients in the control group
and 1% of patients in the pharmacist intervention group
(p=0.01). The trial concluded that pharmacist involvement in medication reconciliation, medication counseling, and telephone follow-up with patients resulted
in reduced ADEs among recently discharged patients.
This is further support for the pharmacist as one of the
key members of the transition of care process, especially
at hospital discharge.

18. Tija J, Bonner A, Briesacher BA, McGee S, Terrill E,

Miller K. Medication discrepancies upon hospital to
skilled nursing facility transitions. J Gen Intern Med
2009;24:6305.
This cross-sectional study examined the number of
drug discrepancies, defined as unexplained differences
among documented regimens, as patients transferred
from the hospital to a skilled nursing facility (SNF).
There were 199 patients with 2319 drugs reviewed upon
admission to the SNF, and of these drugs, there were
discrepancies with 495 (21.3%). Of the patients, 142
(71.4%) had at least one drug discrepancy noted on SNF
admission. The range of discrepant drugs went from 0 to
12 with a mean of 3.5 (SD 2.6). The types of discrepancies that occurred included drug name, dose, and route
of administration; in some cases, there was more than
one type of error for an individual drug. The investigators concluded that drug discrepancies occurred in
almost three-fourths of SNF admissions and, because
of this, stressed the importance of improved documentation and communication during transfers, especially
during the first 2448 hours when patients and their
medical records might still be awaiting evaluation.

17. Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears

RL, et al. Transitions of care consensus policy statement American College of Physicians-Society of General Internal Medicine-Society of Hospital MedicineAmerican Geriatrics Society-American College of
Emergency Physicians-Society of Academic Emergency
Medicine. J Gen Intern Med 2009;24:9716.
This is the first combined policy statement from several medical societies with a focus on improving and
standardizing the transition of care process. It was
developed in July 2007, when many stakeholders held
a consensus conference to address the standardization of patient transitions in health care. More than 30
organizations sent representatives to the Transitions
of Care Consensus Conference (TOCCC). Participating organizations included medical specialty societies

Transitions of Care

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Self-Assessment Questions
21. A 66-year-old man with type 2 diabetes mellitus and
hypertension was admitted to the hospital for community-acquired pneumonia. After being stabilized
and receiving intravenous levofloxacin for 2 days, he
was discharged home yesterday with a prescription
for levofloxacin 500 mg orally, which was filled at
the hospital pharmacy. A nurse reviewed the instructions with him, which were to take 1 pill daily for 3
more days, and he was given the phone number to
schedule a follow-up examination with his primary
care provider (PCP) in 12 weeks. The patient has
lived by himself since his wife died 2 years ago. In
evaluating the domains involved in the transition
of care process for this patient, which one of the
following is most important to reduce the risk of
hospital readmission?

Hg and heart rate 65 beats/minute. His laboratory

values from this morning are potassium 4.8 mEq/L,
blood urea nitrogen 15 mg/dL, and serum creatinine
1.4 mg/dL; these correspond to his chronic baseline
concentrations when not acutely volume overloaded.
He reports being adherent to his home drug regimen
before his hospitalization and does not understand
why he cannot keep the fluid off. The patient remembers he is supposed to limit his salt intake but says he
does not always understand the labels on the packaged food he eats. Which one of the following is the
most likely reason this patient will be readmitted?
A.
B.
C.
D.

A. Destination.
B. Education.
C. Information.
D. Education and information.

24. Five days ago, a 76-year-old man was hospitalized for

hypoglycemia. He has had type 2 diabetes mellitus
for 10 years. About 2 months ago, he was initiated on
insulin glargine in addition to metformin. Although
he was instructed to stop glyburide, he was confused
and continued to take it twice daily. On the day he was
hospitalized, he took his morning glyburide dose but
did not eat breakfast. While in the hospital, he was
reeducated about his antihyperglycemic drugs. The
plan is to discharge him today on metformin 1000
mg two times/day and insulin glargine 20 units/day.
The patient has a daughter who lives nearby, but she
travels a lot for her job. Which one of the following
discharge locations would be best to reduce this
patients risk of an adverse event?

22. A 76-year-old woman was brought to the hospital by her husband for an acute exacerbation of her
chronic obstructive pulmonary disease. After an initial assessment in the emergency department, she
was admitted to the general medicine floor. Two
days later, she has left the floor only once for chest
radiography on her first day of admission. She will
be discharged home from the hospital today with
a prescription for 1 week of prednisone and 3 days
of azithromycin. Which one of the following best
describes the number of transitions in care that
this patient underwent while in the hospital?

A. Daughters home.
B. Home.
C. Home with home health care.
D. Skilled nursing unit.

A. Two.
B. Three.
C. Four.
D. Five.

25. A 57-year-old woman with allergic rhinitis,

dyslipidemia, hypothyroidism, and osteoarthritis
was recently hospitalized for a right lower extremity
cellulitis. She initially received intravenous vancomycin; this was changed to amoxicillin/clavulanate yesterday after culture and sensitivity data became available. The inpatient team noticed she had stopped
taking alendronate a few months ago (she tolerated
the medicine but felt she did not need to take it anymore), so this is being reinitiated at the time of discharge. Her inpatient team plans to discharge her
home tomorrow. Her discharge drugs include amoxicillin/clavulanate 875 mg two times/day, loratadine
10 mg/day, atorvastatin 10 mg/day, alendronate 70

23. A 62-year-old man is hospitalized for the third time

in the past 6 months for fluid overload. He has systolic heart failure, hypertension, and dyslipidemia.
During the present hospitalization, he receives intravenous furosemide and is diuresed back to his dry
weight of 80 kg. His discharge drug list includes furosemide 40 mg two times/day, lisinopril 40 mg/day,
metoprolol succinate 100 mg/day, aspirin 81 mg/
day, and simvastatin 40 mg/day. The patient, who
was born in Belize and speaks English and Spanish,
is given an updated list of his discharge drugs; this
list is reviewed with him before his discharge. His
vital signs today include blood pressure 120/78 mm
PSAP-VII Science and Practice of Pharmacotherapy

Laboratory tests.
Literacy level.
Medication reconciliation.
English as a primary language.

117

Transitions of Care

accuracy, which one of the following specialty clinics

would be best to start with?

mg once weekly, levothyroxine 88 mcg/day, and acetaminophen 1000 mg three times/day. Which one of
the following drugs is most likely to cause adverse
effects in this patient after hospital discharge?

A.
B.
C.
D.

A. Amoxicillin and clavulanate.

B. Atorvastatin.
C. Alendronate.
D. Levothyroxine.

29. As the chief medical officer for a health care system, you are evaluating four hospitals on the transition of care process using the measures reported to
the Agency for Healthcare Research and Quality.
Which one of the following hospitals would benefit the most from a system-wide process change
to improve care transitions?

Questions 26 and 27 pertain to the following case.

M.G. is a 61-year-old woman who suffered a seizure and
was brought to the emergency department for evaluation.
She was initiated on phenytoin and was seizure free during a 7-day hospital stay. The inpatient neurology team
plans to discharge M.G. home on phenytoin 300 mg/day.

Abuse/neglect presence assessed.

Advanced care planning documented.
Caregiver assessment performed.
Confirmation of the patients ability to obtain
drugs.

Hospital 3
(%)

Hospital 4
(%)

Hospital discharge summary to PCP

50

50

80

80

Medication
reconciliation

100

95

90

95

Medication list
given to patient

100

85

100

85

Patient home
environment
assessment

75

75

90

100

Hospital 1.
Hospital 2.
Hospital 3.
Hospital 4.

30. As the pharmacist on an adult internal medicine

ward in a 300-bed hospital, you provide daily clinical coverage for 30 medical patients. Today, four
patients require review before discharge: one admitted for an asthma exacerbation, one for hyperglycemia, one for major depression, and one for diabetic
ketoacidosis. Your institution has adopted the Institute of Medicine (IOM) Transforming Healthcare
2003 campaign. Using the 203 areas of focus
related to transitions of care outlined by the IOM
(medication reconciliation, care coordination,
and self-management/literacy), which one of the
following patients has the highest risk of a transition of care issue at discharge?

Problem drugs.
Principal diagnosis.
Patient support.
Previous hospitalizations.

28. You work for a large health care system with 6 hospitals,
15 outpatient primary care clinics, and 5 specialty clinics
that address cardiology (including heart failure), orthopedics, endocrinology, neurology, and rheumatology.
As the chief of pharmacy, you must evaluate standard
operating procedures for ensuring medication accuracy
during transitions of care. Based on national health
organization procedures pertaining to medication

Transitions of Care

Hospital 2
(%)

A.
B.
C.
D.

27. The hospital requires two separate assessments of

M.G.s preparedness for discharge. The 8Ps tool
includes the reason for M.G.s hospitalization, reason for seizure, and drug list (i.e., phenytoin, insulin glargine, glipizide, atorvastatin, lisinopril/hydrochlorothiazide, aspirin, and clopidogrel). The tool
notes that this is M.G.s first hospitalization since
her knee replacement 18 months ago. The patient
is being discharged home, where she lives with her
husband. She has a scheduled follow-up in the outpatient neurology clinic within 1 week. Which one
of the following issues identified by the 8Ps assessment is most likely to put M.G. at risk of a postdischarge adverse event?
A.
B.
C.
D.

Hospital 1
(%)

Measures

26. As the patients discharge pharmacist, you use the

general assessment of preparedness (GAP) tool to
assess her before discharge. Which one of the following GAP tool assessments would be most
important to clear M.G. for discharge?
A.
B.
C.
D.

Cardiology clinic.
Endocrinology clinic.
Neurology clinic.
Rheumatology clinic.

118

Measures

Patient 1

Patient 2

Patient 3

Patient 4

Admission
diagnosis

Hyperglycemia

Major
depression

Diabetes
ketoacidosis

Asthma
exacerbation

Discharge
diagnosis

Urinary
tract
infection

Gout

Diabetes

Communityacquired
pneumonia

Pain score
at discharge

2/10

8/10

7/10

0/10

Tobacco use Yes

No

No

Yes

History of
depression

No

Yes

No

Yes

PSAP-VII Science and Practice of Pharmacotherapy

A.
B.
C.
D.

Patient 1.
Patient 2.
Patient 3.
Patient 4.

for discharge home. You are part of a multidisciplinary team working to transition the patient from
the hospital. The team consists of you (the pharmacist), the orthopedic surgeon, and the physical therapist. Which one of the following would be most
beneficial to add to your discharge team?

31. Today, 5 days after she was admitted to the internal medicine service for pancreatitis, a 55-year-old
woman is being discharged home. She has received
her reconciled discharge drug list and has undergone counseling from a pharmacist on all of her
drugs. In addition, a nurse discussed with her the
laboratory orders she will need to follow up on as
an outpatient. The patient will receive a follow-up
phone call by a pharmacist in several days and will
also receive a patient satisfaction survey related
to the hospitalization. Which one of the following negative outcomes will most likely be prevented in this patient because of these discharge
interventions?
A.
B.
C.
D.

A.
B.
C.
D.

35. A 74-year-old woman was hospitalized to rule out

a myocardial infarction. Her home drug regimen
includes levothyroxine 50 mcg/day, atorvastatin
10 mg/day, aspirin 81 mg/day, calcium 600 mg
two times/day, and albuterol 1 or 2 puffs 15 minutes before exercise. While in the hospital, a myocardial infarction was ruled out. The patient was
instructed to perform stretching, heel raises, and
resistance band exercises, and to walk for 10 minutes daily. She was discharged from the hospital to
home 2 days ago with no changes to her home drug
regimen. Which one of the following additional
interventions would be most likely to prevent an
emergency department visit in this patient?

Potential adverse drug events (ADEs).

Duplicate laboratory orders.
Poor medication adherence.
Patient dissatisfaction.

32. A 43-year-old man has been hospitalized for 3 days

for dehydration and altered mental status. As part of
the inpatient medical team, you have been asked to
assess and score his readiness for discharge home.
Which one of the following tools would be most
appropriate to administer to this patient?

A. A hospital mailing with telephone numbers to call.

B. Weekly telephone calls from her physical
therapist.
C. A nurse home visit within 48 hours.
D. A call to the patients pharmacy within 24 hours.

A. The 8Ps risk assessment tool.

B. GAP.
C. TARGET (Tool for Addressing Risk: A Geriatric Evaluation for Transitions).
D. Brief-PREPARED survey instrument.

36. A 49-year-old man who was admitted for symptoms

of alcohol withdrawal is being discharged from the
hospital to home today. His hospitalist has already
communicated the patients discharge plan to his
PCP. The patient knows how to contact the hospitalist if an issue arises before his posthospital discharge visit with his PCP. Which one of the following actions is most important as the patient transitions from the hospital to home?

33. A 70-year-old man with dyslipidemia, heart failure, and osteoarthritis is scheduled to have a left
total knee replacement next month. He has Medicare health insurance as well as a Medicare Part D
prescription plan. His will likely be discharged after
23 days and then take part in outpatient physical
therapy. His wife has agreed to drive him to all of
his physical therapy and follow-up appointments.
Which one of the following is most likely to
result in hospital readmission after this patients
surgery?
A.
B.
C.
D.

A. Make his discharge summary available to the

PCP in a timely fashion.
B. Ask him to identify the provider responsible
for his care upon discharge.
C. Present the patient with a copy of his reconciled drug list.
D. Communicate the patients information in a
secure fashion.

Heart failure.
Overwhelming spousal support.
Age older than 65 years.
Medicare Part D coverage.

37. A 57-year-old woman with asthma presents to the

emergency department with a fever and shortness
of breath. She receives a diagnosis of communityacquired pneumonia and is initially admitted to the
medical intensive care unit for potential intubation.

34. An 80-year-old woman who was admitted for an

elective right total hip replacement is being prepared
PSAP-VII Science and Practice of Pharmacotherapy

Advanced practice nurse.

Occupational therapist.
Transition coach.
Licensed clinical social worker.

119

Transitions of Care

discharged to a skilled nursing facility. Which one

of the following is the most important target to
reduce ADEs resulting from her transition to the
skilled nursing facility?
A. Follow up with her PCP.
B. Laboratory follow-up.
C. Medication reconciliation.
D. Family member involvement.

When her oxygenation improves, she is moved to

the medical ward. The patients home drugs include
an albuterol rescue inhaler and fluticasone 88 mcg 2
puffs two times/day. Her drug list is reconciled by
the emergency department pharmacist. After a 5-day
hospital stay, she receives standard discharge counseling and is discharged home with oral doxycycline
to complete a 10-day course of antibiotics. She is
instructed to follow up with her PCP in 12 weeks.
During which one of the following care transitions
is an ADE most likely to occur in this patient?
A. Home to emergency department.
B. Emergency department to inpatient hospital
stay.
C. Medical intensive care unit to the medical ward.
D. Inpatient hospital stay to home.
38. A 30-year-old woman who was admitted to the hospital for injuries sustained in a motor vehicle crash
is being discharged home. As the discharge pharmacist, you meet with her regarding her drug list, discussing drug name, route, strength, indication, and
who to contact if she has a drug-related issue (e.g.,
an adverse reaction or difficulty obtaining refills).
Which one of the following steps will best ensure
that the patient understands her discharge drug
regimen?
A. Facilitate scheduling the patients discharge
follow-up appointment.
B. Call the patient in a few days to verify understanding of her drug regimen.
C. Confirm that the patient knows when to call
about pending laboratory test results.
D. Assess the patients insurance status and ability to pay for her drugs.
39. A 59-year-old man with systolic heart failure was
admitted for fluid overload secondary to running
out of furosemide 3 days ago. He was given intravenous furosemide and placed back on his home dose
of furosemide (40 mg two times/day). In addition,
he was continued on metoprolol succinate 150 mg/
day, lisinopril 20 mg/day, simvastatin 40 mg/day,
and aspirin 81 mg/day. Which one of the following is most important to stress to this patient during his transition from the hospital to home?
A. Medication adherence.
B. Laboratory follow-up.
C. Follow up with his PCP.
D. Daily weights.
40. An 80-year-old woman was hospitalized for altered
mental status related to accidentally ingesting too
many of her pain drugs at home. Now she is being

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