Pharmacists’ Expertise Can Improve Patient Outcomes in Transitions of Care
With transitions of care inclusive of multiple health care settings, each provider must play a specific role to ensure overall improved patient outcomes.
When pharmacists are key players assisting in transitions of care (TOCs), patient outcomes are improved and hospital readmissions are reduced, among several other patient benefits.
“Pharmacist involvement in transitions of care improves patient outcomes and reduces readmission rates,” wrote the authors of a study published in the Journal of the American College of Clinical Pharmacy (JACCP).1 “Pharmacists have demonstrated an impact by providing face-to-face education to patients on new medication therapies, identifying adverse drug reactions, and ensuring medication therapy is appropriate for each medical condition.”
TOCs occur when patients are moved from one health care setting to another. | image credit: Mcgui / stock.adobe.com
Pharmacists have long been considered key providers within health care. From their patient-facing relationships to their widened scope of expertise in medicine, pharmacists are in a unique position within health care. Industry experts believe pharmacists can serve a key role in alleviating ongoing issues within health care.
READ MORE: 5 Questions With a Pharmacist: DeLon Canterbury From GeriatRx
“The [Centers for Medicare & Medicaid Services] (CMS) use 30-day readmission rates to determine hospital reimbursement rates and can penalize up to a 3% reduction in payment; therefore, pharmacists can increase CMS reimbursement rates by decreasing 30-day readmission rates,” the authors continued.1
TOC is the next area within health care that is using the expertise of pharmacists to provide better patient outcomes. If integrated correctly, according to the authors, pharmacists will be able to lower health care costs and reduce hospital admission rates.
“Our study identified that the interventions completed by a pharmacist can help improve patient care by providing education to close gaps in a patient’s understanding of their medication therapy, correct errors in dosing of medication therapies, recognize harmful [adverse] effects that could result in discontinuing a medication, and facilitate medication affordability by providing patient assistance forms or co-pay cards,” wrote the authors.1
What Are TOCs?
According to CMS, TOCs occur when patients are moved from one health care setting to another. These health care settings include hospitals, ambulatory primary care, ambulatory specialty care, long-term care, home health, and rehabilitation facilities. To ensure a successful TOC, patients rely on the provider at each respective setting: Physicians, ambulatory care experts, and others must assist as patients switch health care settings.2
Furthermore, the National Association of Clinical Nurse Specialists (NACNS) explains the various instances in which a TOC would be necessary and provides examples. TOCs can occur within a health care setting, between 2 settings, across health states, or between providers. An example is if providers move a patient from a palliative care setting into hospice or assisted living.3
“[TOCs] are a set of actions designed to ensure coordination and continuity. They should be based on a comprehensive care plan and the availability of well-trained practitioners who have current information about the patient’s treatment goals, preferences, and health or clinical status,” according to the NACNS website.3
TOCs have multiple terminologies and can also be referred to as care transitions, or simply transitional care. While much of the focus during TOCs is on the patient’s physical setting, their overall condition and the care they receive during transitioning is the most important aspect of a successful TOC.
“For example, in the course of an acute exacerbation of an illness, a patient might receive care from a [primary care provider] or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility,” according to NACNS.3
TOCs can even be the act of moving a patient from a specific health care setting to their home, but they always consist of a trained health care professional providing care to a patient; a TOC is never the discontinuation of care.
The Pharmacist’s Role in TOCs
Few other entities have been as supportive of pharmacists’ roles in TOCs as the National Transitions of Care Coalition (NTOCC). Founded in 2006 by the Case Management Society of America and Sanofi US, the NTOCC consists of a collection of pharmacists and other providers dedicated to finding solutions and addressing gaps within the TOC landscape, according to the official NTOCC site.4
In 2021, NTOCC made a call to action to the health care industry and gathered a group of interdisciplinary professionals to discuss issues facing pharmacists who provide TOC services. By discussing and gaining alignment on pharmacists’ roles in TOC, the NTOCC hoped its pharmacist task force could further define the importance of pharmacists in providing TOC services.5
In collaboration with the Pharmacy Quality Alliance (PQA), NTOCC representatives hosted a webinar about pharmacists’ role in TOCs, starting the discussion with an introduction to TOC challenges. Amina Abubakar, PharmD, owner and CEO of Avant Pharmacy & Wellness Center, listed challenges including poor communication between settings, a lack of pharmacists in TOCs, minimal consensus of the pharmacist’s role, financial reimbursement, and siloed technology between settings, according to a recap of the PQA webinar.6
“We all agreed that highlighting the role of the pharmacist was very important. Based on the current data and the literature, we know that the pharmacist’s scope of practice elevates and improves TOCs,” said Klodiana Myftari, PharmD, BCACP, director of clinical pharmacy relations at the American Medical Association.5
According to the JACCP article, pharmacists’ expertise in medications has created an opportunity for them to step in and lead interdisciplinary care teams focusing on TOCs. More specifically, the authors believe each team should have a dedicated pharmacist who focuses only on TOCs, as other pharmacist duties outside of TOCs can be time-consuming and won’t allow for TOC interventions.1
“Findings from this study demonstrate that pharmacist involvement during discharge TOCs helps to identify drug-related problems which may lead to improved patient care. Further studies are needed to analyze the effect on cost of decreasing readmission rates,” concluded the authors of the study.
Furthermore, looking back at the PQA and NTOCC partnership, several entities within health care are motivated to develop TOCs with the help of pharmacists. In curating its “Ten Principles of Pharmacists in Transitions of Care,” the pharmacist TOC task force is aligned with other crucial health care providers and is continuously looking to improve patient outcomes through TOCs.
“The future is indeed bright in positioning pharmacists to play a transformational role in vital areas in the era of post–COVID-19 health care—and NTOCC, the Pharmacist TOC Task Force, and Advisory Committee experts are helping accomplish this in the area of effective management of TOCs. We encourage practitioners to send us comments or thoughts on this initiative and the Ten Principles as we work together to support all pharmacists in this role,” concluded Sara Panella, PharmD, BCPS, and Norris Turner, PharmD, PhD, in an NTOCC statement.7
To read these stories and more, download the PDF of the Total Pharmacy April issue here.
References
1. Tasseff N, Axtell S, Nixon B. Effect of extended pharmacist involvement in discharge transitions of care on hospital readmission rates: prospective, randomized, parallel arm design trial. JACCP. 2023;7(1):8-14. https://doi.org/10.1002/jac5.1887
2. Eligible Professional Meaningful Use Menu Set Measures (Measure 7 of 9). CMS; 2024. Accessed February 10, 2025. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/8_Transition_of_Care_Summary.pdf
3. Definitions of transitional care. National Association of Clinical Nurse Specialists. Accessed February 10, 2025. https://nacns.org/resources/toolkits-and-reports/transitions-of-care/definitions-of-transitional-care/
4. About the National Transitions of Care Coalition. National Transitions of Care Coalition. Accessed February 11, 2025. https://www.ntocc.org/about-banner-1
5. PQA quality forum: the essential role of pharmacists in transitions of care. Pharmacy Quality Alliance. August 18, 2022. Accessed February 11, 2025. https://www.youtube.com/watch?v=dJDGrbG3iCg
6. Valdez OE. Quality forum review: the essential role of pharmacists in transitions of care. Pharmacy Quality Alliance. September 19, 2022. Accessed February 11, 2025. https://www.pqaalliance.org/index.php?option=com_dailyplanetblog&view=entry&category=quality%20forum&id=188:quality-forum-review-the-essential-role-of-pharmacist-in-transitions-of-care
7. Panella S, Turner N. Pharmacist transitions of care task force, advancing a new standard of care in our post-COVID-19 era of healthcare. National Transitions of Care Coalition. January 19, 2022. Accessed February 11, 2025. https://www.ntocc.org/https/static1squarespacecom/static/5d48b6eb75823b00016db708/t/61e644f7fa858224c4ea6c60/1642480888393/tocpharmaciststaskforce10principles28129pdf
