Authors: Elizabeth Pham, 2019 PharmD CandidateAlison Stevens PharmD, BCPS; Assistant Director of Health System and Acute Care, Office of Experiential Education/Assistant Professor, Department of Pharmacy PracticeSt. Louis College of Pharmacy
Transitions of care (TOC) is a process designed to maintain the safety and care of patients when transferring between different health care settings or different health care professionals within the same setting. However, transitioning patients can be complex, resulting in medication errors. In the United States, medication errors and adverse drug events contribute to almost 700,000 emergency department visits and over 100,000 hospitalizations.Factors often attributed to causing adverse drug events include breakdowns in communication, accountability, incomplete medication reconciliation and insufficient patient and caregiver education.1 All of these elements contribute to hospital readmissions, stressing the importance of an effective TOC process. Pharmacists can play a fundamental role in this process by providing interventions such as medication reconciliation, patient counseling and follow-up telephone calls. In fact, various institutions that have piloted the use of pharmacists on their TOC team found improvement in outcomes such as a decrease in the number of return emergency department visits and a reduction in medication discrepancies.2-4
Creating a Transitions of Care Introductory Pharmacy Practice Experience
Pharmacists clearly have a role in the TOC process that continues to expand; therefore, pharmacy schools should start exposing their students to care transitions as a pharmacy practice experience. Though the data on implementing an introductory pharmacy practice experience (IPPE) focused on TOC is lacking, certain institutions have started to pilot advanced pharmacy practice experiences (APPE) concentrated on TOC with positive results. Pharmacy students that participated in these TOC APPEs not only received hands on patient care experience, but also greatly impacted their sites. One institution increased the number of patients assessed by their TOC team from 10 patients to approximately 15 to 20 patients per day with student integration.5
At the St. Louis College of Pharmacy, TOC is included in the Pre-APPE curriculum as an IPPE course. The course spans both fall and spring semesters of the third professional year. As part of the course, student pharmacists are made aware of the negative health outcomes of an ineffective TOC process and have an opportunity to impact the TOC process in various settings. Additionally, the students have the chance to act as part of the health care team and interact with other health care professionals to emphasize the importance of collaboration at crucial transitions.
The Student Experience
The majority of the course is spent completing 20 experiential hours in either ambulatory care, long-term care, community or health systems. To understand what TOC looked like in all four health care settings, a student from each setting was interviewed to talk about their experience.
In ambulatory care, patients transition from the inpatient setting to the outpatient setting. Rachel Marchi, a student assigned to the ambulatory care setting, utilized telepharmacy to complete her TOC activities. When she was able to reach the patients, she asked questions regarding their current medications and identified any barriers to adherence. Additionally, each patient interaction lasted approximately 10 to 15 minutes. When talking about her overall experience she stated that, “I feel like we were able to optimize the care of each patient by making their appointment visit more focused on what they wanted to come in for. Overall, I really enjoyed my experience and I feel like it helped prepare me for my future APPE rotations.”
Likewise, in long-term care, patients mainly transition out of the hospital and into a long-term care facility. Bradley Collins, a student that completed his TOC IPPE rotation in long-term care, spent most of his time on the computer analyzing the medication lists for each patient transferred to the nursing facility. According to Bradley, it took about two hours to complete a full assessment for each patient. When talking about his experience, Bradley said that “having the opportunity to see what TOC looks like in a long-term care setting was really awesome, since this is not something we get a lot of exposure to in school.”
In the community setting, patients transition from the inpatient environment and back into the community, or between different pharmacies. Performing TOC activities in the community setting can be challenging due to communication barriers between the pharmacist and hospital and lack of integration between the computer systems from either setting. Moreover, staffing issues and the amount of time needed to complete a TOC intervention may not always be feasible. Meghin Moynihan, who completed her TOC IPPE rotation in the community setting, was only able to transfer prescriptions and perform patient adherence calls. When talking about her overall experience Meghin said she “really enjoyed her time at the pharmacy” but felt that her TOC experience was very limited.
On the other hand, in the health system setting, patients transition from the outpatient environment to an inpatient setting, and then back to the community. Ivan Porto, a student that completed his TOC IPPE in a hospital, states, “I did a lot of medication reconciliation for patients that were admitted to the service and medication education for patients that were going to be discharged from the hospital.” When talking about his overall experience Ivan claims, “My preceptor gave me a lot of opportunities to really see what TOC looks like in a health systems setting, so I really enjoyed my experience.”
The Preceptor Perspective
In addition to the students’ experience, preceptors from each setting were interviewed to gain perspective on how they integrated the IPPE course into their respective practices. Dr. Justinne Guyton, who practices in ambulatory care at the St. Louis Department of Public Health, set up the rotation so students called patients scheduled to come for a follow-up visit after a recent hospitalization. Patients were picked for the students ahead of time by Dr. Guyton who determined which patients would fit the criteria for a TOC intervention. In contrast to Dr. Guyton’s ambulatory care site, Dr. Steven Hebel’s long-term care site at Corum Health Services, Inc. had students perform medication reconciliation using a standardized form. The form compared patient medication lists from different settings (home, doctor’s office and hospital discharge) and different computer systems (the skilled nursing facility and Corum pharmacy). If the students identified any medication discrepancies, omissions, and/ or duplications they had to assess the patient’s risk for hospital readmission and adverse events. Another preceptor, Dr. Andrew Crannage, created an “IPPE collaboration” between the other three TOC preceptors at his health system site, Mercy Hospital St. Louis. He set the rotation up as a shared experience where the students would spend time with each preceptor performing a specific TOC task each day they were scheduled. Tasks included an orientation day, discharge education day, home medication reconciliation day, and a day where students rounded with a pharmacist and health care team. Finally, Dr. Joshua Boudeman, a pharmacist at the solid organ transplant and oncology specialty Walgreens at SSM St. Louis University Hospital, had his students perform medication reconciliation for the solid organ transplant and oncology patients preparing for discharge. Students built patient profiles for new oncology referrals that the pharmacy received, including their medication list. This list was either obtained from the patient or, preferably, provided by the prescriber's office and confirmed by the patient.
Having an effective TOC process in place is crucial to improving health outcomes for patients. Pharmacists are a vital component of the TOC team, and pharmacy schools should begin integrating care transitions into the experiential curriculum. Adoption of these experiences could lead to improved student education on TOC and positive TOC outcomes at rotation sites.