Role of clinical pharmacists and pharmacy support personnel in transitions of care

Abstract

Patients moving between health care settings or providers are at increased risk of complications, including unplanned hospital readmissions and medication errors. Several actions must occur in concert with members of the health care team and across settings to ensure coordinated and continuous care for patients undergoing these transitions of care (TOC). Clinical pharmacists support patients during care transitions by providing interventions and services designed to improve medication outcomes. Clinical pharmacists and team members who support clinical pharmacist activities (eg, pharmacy students, technicians, and residents) are located throughout the care continuum, from acute care to care in the community, with each contributing to improved TOC outcomes. This article provides information on evidence of high‐impact clinical pharmacist TOC practices to serve as a practical guide for practitioners interested in starting or improving TOC activities. This article also addresses current and emerging best practices and offers suggestions for improving clinical pharmacist involvement in care transition activities.

Quality measures of clinical pharmacy services during transitions of care

“…Pharmacists' roles in medication reconciliation processes have previously been described. 11 Studies have reported positive outcomes from pharmacistdirected processes to identify medication discrepancies in institutional and hospital settings (Appendices 1 and 2). The most-often measured medication discrepancies are identified as (1) percentage of patients identified to have at least one medication discrepancy, (2) number of medication discrepancies identified per patient, and/or (3) percentage of medication discrepancies by type.…”

“…Shorter time to completion of reconciliation is associated with positive patient outcomes, but this varies by care setting. Pharmacists' roles in medication reconciliation processes have previously been described 11 …”

“…If an increased length of stay is experienced, it should be interpreted in aggregate with any impact on related metrics, such as reduced 30‐day readmission rates. Direct costs can be minimized by integrating pharmacist extenders (eg, partnerships between health systems and schools of pharmacy) into practice models that delegate specific TOC activities appropriate to each learner's level of training 11 . Of importance, administrators must be careful not to detract from any major learning experiences required by educational accrediting bodies.…”

Nephrology practice and research network opinion paper: Pharmacists' perspectives on the Advancing American Kidney Health initiative

“…Patients with CKD undergo many transitions of care that can introduce MTPs (Figure 1). Clinical pharmacy services are integral during care transitions with the role of the clinical pharmacist recently outlined 20 . Specific to kidney disease, a patient with CKD will transition from their primary care provider to a nephrologist as CKD progresses, with most nephrologist referrals occurring in CKD stages 4 and 5 (Figure 1).…”

“…We believe that a readily accessible clinical pharmacist is the optimal provider to complete this as part of the CMM process. This “central clinical pharmacist” can serve as a coordinator of medication‐related care between providers, hospitals, other health care organizations, and dispensing pharmacies 20 . Having nephrology‐trained pharmacists available either physically or virtually in CKD and dialysis clinics, or patient homes, would be ideal in any transition of care 23 …”