The National Transitions of Care Coalition estimated that the United States wastes around 30 to 50 billion dollars in unnecessary medical expenditures to fix transitional care errors each year. Approximately 60% of which are medication related errors. With this in mind, the argument can be made that more emphasis should be placed on pharmacist-led transitions of care (TOC) programs to ensure patients are properly educated on their new medications. Furthermore, this would be a great area for pharmacists to make a positive impact, while expanding our scope of practice. The continuing trend of pharmacists expanding their scope of practice is becoming more and more relevant each year. For example, H.R. 2759/S. 136 is a bill currently in discussion that would add pharmacists to the providers list eligible for Medicare part B service reimbursement. While provider status may continue to elude our profession, pharmacists are the ideal choice to lead TOC programs-- and can successfully implement these programs now. Furthermore, these programs would likely pay for themselves by reducing emergency medical costs paid by health systems.
To begin, what is a transition of care program? A transition of care (TOC) program consists of a healthcare professional that follows up with a patient via phone call after they are discharged from the healthcare facility to return home. The goal of the program is to ensure the accurate communication of all pertinent healthcare information. This can include things such as discussing barriers, medication adherence, and any new developments in their conditions since discharge.
Below is an illustration of a standard TOC program timeline as an example:
The exact process of the TOC program can vary depending on the specific patient and hospital. Despite any difference in TOC follow up protocol, it remains unchanged that transitional follow up is effective for reducing readmission rates among high-risk patients, and reducing overall health care expenditure per patient. By understanding why TOC programs are beneficial, and furthermore, understanding why pharmacists are the ideal candidate to lead these programs, we can advocate for our profession and improve the health outcomes of patients along the way.
One noteworthy case published in the NCBI in 2016 is a great example of small details going unchecked causing big problems for our patients. The case report follows a geriatric patient who was discharged with the medication thiothixene (Navane) by mistake instead of amlodipine (Norvasc). The patient continued to take thiothixene for 3 months and suffered severe mental and behavioral side effects. The patient's untreated hypertension led to severe chest pain and readmission 3 months later. At that time, a different specialist prescribed the patient citalopram and alprazolam to treat these new mental and behavioral side effects that were labeled as depression and anxiety. A few weeks after this, the patient suffered a fall and was taken to the emergency department where the mistake was finally caught many months later. This case report serves as a great illustration as to why TOC programs are crucial for catching and fixing medication errors. Pharmacist-led TOC programs can cater specifically to the new medications that can be overwhelming for patients to sort out by themselves.
As stated previously, many problems during transitions of care arise from medication related problems. There are many notable studies that bolster data to suggest that TOC programs have a significant improvement for the outcome of the patient, while also saving the health system on overall expenditures. One study published in The American Journal of Accountable Care in 2018 contacted 90% of the patients enrolled in the intervention group at 72 hours post discharge. From this group, they found that 86.4% of the 185 patients contacted had a medication related issue. (Fig. 1) These medication related issues ranged from not taking their medication correctly, to discontinuing the medication due to the side effect profile. What’s more, the study found that the readmission rate for patients involved in the TOC program compared to routine care (no follow-up) was significantly lower for patients enrolled in the TOC program. These findings were further amplified by the patients all being categorized as high risk for readmission due to receiving more than 10 medications, having a diagnosis of pneumonia or congestive heart failure, or receiving anticoagulation therapy. The study concluded that a system wide TOC program would save the health system $582 per patient.
Furthermore, a budget impact analysis published in the Journal of Managed Care & Specialty Pharmacy in 2018 set out to determine the impact of regulated pharmacists-led TOC programs for all Medicaid patients. The authors found that pharmacist-led TOC programs could result in a savings of $25 million dollars to Medicaid over a two year time period. This was found by performing a decision tree analysis from the health system payer’s point of view for treatment of high risk patients. (Fig. 2) The main culprit for Medicaid waste was found to be mismanagement of medications leading to costly interventions that could potentially be avoided.
And finally, a study published in the American Journal of Health-System Pharmacy in 2020 found that the 30 and 90 day readmission rates for chronic heart failure patients were significantly lower when enrolled in a pharmacist-led TOC program. This was in comparison to having no follow-up, and had a difference of 13% of patients readmitted from the TOC group versus 28% from the control group. This highlights the ability of pharmacists to improve health outcomes in this setting.
With all of the presented data, and the high prevalence of medication related problems during transitional care, it is clear that medication specialists should lead such a crucial step in a patient's health care. Pharmacists are well equipped to be at the helm of this venture. With such a definitive way for pharmacists to make a dramatic impact on the health outcomes of patients, it is clear that pharmacists-led TOC programs are a great option for all pharmacists to pursue to benefit patient health outcomes, while saving the health system money as well.
References:Cua, Yvette M, and Sunil Kripalani. “Medication Use in the Transition from Hospital to Home.” Annals of the Academy of Medicine, Singapore, U.S. National Library of Medicine, Feb. 2008, www.ncbi.nlm.nih.gov/pmc/articles/PMC3575742/.
Da Silva, B., & Krishnamurthy, M. (2016, September 7). The alarming reality of medication error: A patient case and review of Pennsylvania and national data. Retrieved August 20, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5016741/
Tully AP, et al. Evaluation of medication errors at the transition of care from an ICU to non-ICU location. Crit Care Med 2019;47:543-549.
Melody, Karleen T, et al. “Optimizing Care Transitions: The Role of the Community Pharmacist.” Integrated Pharmacy Research & Practice, Dove Medical Press, 22 Apr. 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC5741037/.
Ni, Weiyi & Colayco, Danielle & Hashimoto, Jonathan & Komoto, Kevin & Gowda, Chandrakala & Wearda, Bruce & McCombs, Jeffrey. (2018). Budget Impact Analysis of a Pharmacist-Provided Transition of Care Program. Journal of managed care & specialty pharmacy. 24. 90-96. 10.18553/jmcp.2018.24.2.90.