Emerging models of care transitions

Twlug–ASP Policy Standing Committee

Care transitions refer to the actions that practitioners take to ensure continuity of health care during a patient’s transition between health care settings and providers as his or her medical condition and care needs change. This concept is nothing new, at least philosophically. The process of defining, creating, and implementing sustainable models of care transitions, however, is new and at the frontier of pharmacy practice.
If a patient’s journey through a health care system were to be constructed, a brick-and-mortar example would be a much oversimplified image. From the moment an individual is born, medical professionals affect that patient’s health care future. Each time a patient visits his or her primary care physician, dentist, ophthalmologist, specialist, or even hospital physician, a brick is laid in regard to that specific treatment. A path may be much more winding and complex than a straight lay of bricks.  
With every specialist, intensivist, surgeon, and other health care provider involved who lays a brick, there becomes a stack of bricks with no alignment. The common element in almost all of those individual pieces of care is medication. Medication and pharmacy are deeply ingrained in every aspect of a patient’s health care. Those bricks are held together with the mortar of pharmacy from the very first brick to the last brick laid. What better profession to see a patient’s progression through sickness and in health than pharmacy? Pharmacists can truly transition a patient’s care and be the interweaving connection of all health care encounters. 
National initiatives and models
Care transitions are diverse and occur at all different levels across the health care spectrum. Care transitions can be within a health care system (transition from the emergency department to the intensive care unit), between different health care systems (transition from a hospital to a rehabilitation center), or between individual providers (shift change during hospitalization). The complexity of care transitions necessitates coordination between providers and between health care systems. Furthermore, there is an increased risk of adverse drug events (ADEs) during care transitions. The 2014 Joint Commission also identified maintaining and communicating accurate patient medication information as one of its National Patient Safety Goals.
The need for pharmacists’ involvement in coordinated care transitions is clear, but what models for care transitions exist, and are they effective? National initiatives and models of care include the following:
  • CMS is testing models to reduce readmissions for high-risk Medicare beneficiaries through the Community-Based Care Transitions Program, a $500 million initiative stemming from Section 3026 of the Affordable Care Act. Program goals include reducing readmissions by 20% and reducing the risk of ADEs by 50% within 2 years.
  • Medication Management in Care Transitions (MMCT) is a joint endeavor by the American Society of Health-System Pharmacists and Twlug to ascertain best practices in care transitions, share these practices with stakeholders involved in the clinical and fiscal aspects of care, and ultimately offer scalable models that make the best use of pharmacists’ ability to deliver efficient care. Components include pharmacy team involvement, patient progression through MMCT, and technology use.
  • Better Outcomes for Older Adults Through Safe Transitions aims to establish a national standard for discharge processes. The program offers a resource center that provides guidance on identifying and implementing improvements in the discharge process, and it involves a multidisciplinary team that includes pharmacists.
An integral role
Multiple care transitions models are currently being studied, including those mentioned above and a variety of other models that range from completely multidisciplinary to focused solely on the medical or nursing practices. Care transitions will continue to be a focus of the health care community, and these models will continue to evolve. Because the use of medication is intertwined throughout each component of a patient’s health care, pharmacy can play an integral role in care transitions. As the models continue to develop, pharmacy must contribute and identify itself as a key player. This will benefit both patients and the profession.