EXPERIENCE

Impact of a transition-of-care pharmacist

during hospital discharge
Lauren Balling, Brian L. Erstad, and Kurt Weibel

Lauren Balling, PharmD, Clinical

Abstract Pharmacist, Banner University Medical
Center, Tucson, AZ; at time of study,
Clinical Staff Pharmacist and Instructor,
College of Pharmacy, University of Arizona,
Objective: To assess the impact of a transition-of-care pharmacist during Tucson, AZ, and Banner University Medical
hospital discharge. Center, Tucson, AZ

Brian L. Erstad, PharmD, Professor and

Setting: An academic medical center in southern Arizona. Head, Department of Pharmacy Practice
and Science, College of Pharmacy,
University of Arizona, Tucson, AZ
Practice description: One pharmacist coordinated patient discharges in
two inpatient units from August 2012 through July 2013. The pharmacist at- Kurt Weibel, MS, PharmD, Director,
tended interdisciplinary discharge coordination meetings, ensured appro- Pharmacy Services, Banner University
Medical Center, Tucson, AZ
priate discharge orders, facilitated the filling of medications, and educated
patients on discharge medications. Correspondence: Lauren Balling,
PharmD, Banner University Medical Center,
1501 N. Campbell Ave., P.O. Box 245009,
Practice innovation: The implementation of a transition-of-care pharma- Tucson, AZ 85724; lauren.balling@
cist to provide discharge medication reconciliation and education. bannerhealth.com

Disclosure: The authors declare no

Main outcome measures: Readmission rates and medication interventions relevant conflicts of interest or financial
relationships.
made by the pharmacist at discharge.
Previous presentation: Portions of
the work were presented as a poster
Results: The pharmacist was involved in the education of 1,011 patients and presentation at the American College of
performed 452 interventions. There were more readmissions per month in Clinical Pharmacy 2014 Virtual Poster
the control year versus the year of pharmacist involvement (median 27.5 vs. Symposium, May 20, 2014, where it was a
finalist and selected as runner-up.
25, P = 0.0369). Interventions made by the pharmacist to improve discharge
management included starting an omitted medication (23.5%), prevent- Received May 5, 2014. Accepted for
publication January 14, 2015.
ing multiple discharge problems (16.4%), avoiding duplication of therapy
(15.7%), correcting insurance issues related to medication coverage (12.2%),
changing an improper medication dose or quantity (11.3%), changing an
inappropriate prescription for a medication (5.1%), preventing a drug in-
teraction (3.3%), and resolving other problems (12.6%). The most common
medication classes involved were antimicrobial agents (9.1%), anticoagu-
lants (8%), antihyperglycemic agents (3.8%), other drug classes (24%), and
multiple drug classes (35%).

Conclusion: A transition-of-care pharmacist is in a unique position to ed-

ucate patients on hospital discharge, to intercept a substantial number of
medication errors, and to resolve insurance issues that may lead to adher-
ence problems. These improvements in care may result in reduced hospital
readmission rates.

J Am Pharm Assoc. 2015;55:443–448.

doi: 10.1331/JAPhA.2015.14087

Journal of the American Pharmacists Association j apha.org JU L/A U G 2015 | 55:4 | JAPhA 443
EXPERIENCE TRANSITION-OF-CARE PHARMACIST
T ransitions of care describes patient movement from
one health care setting to another. An estimated 60%
of all medication errors occur during times of care tran-
sitions, and one in five patients discharged from hospi-
tals has a related adverse event, 72% of which are related
to medications.1 Data suggest that counseling patients
before discharge reduces medication discrepancies and
improves adherence.2 Pharmacists are medication ex-
perts and are in a unique position to provide such coun-
seling and ensure medication reconciliation during the
discharge process.3–5 Further, pharmacists can facilitate
patient access to all medications prescribed by making
sure patients can afford them.6
Pharmacists are currently underused in care transi-
tions. In a review of pharmacists’ services in U.S. hos-
pitals, only 5% of hospitals reported that pharmacists
provided admission histories, and only 49% reported
that pharmacists provided medication counseling.7 Dif-
ferences in hospital and outpatient formularies and the
initiation or discontinuation of medications at discharge
increase the chance of drug-related problems that phar-
macists can help intercept.8
Objective
The purpose of this quality improvement project was to
assess the impact of a transition-of-care pharmacist dur-
ing hospital discharge.
Methods
This project was conducted at a 487-bed academic teach-
Key Points
Background:
❚❚ Transitions-of-care will continue to be a focus
of hospitals due to a readmission reduction
program from Medicare that started in 2012.
❚❚ There are currently few studies showing the
impact that pharmacists can have in the dis-
charge process and preventing readmissions.
❚❚ Several studies have shown that there are a
large number of medication errors at hospital
discharge and that a large percentage of hos-
pital readmissions are due to a medication ad-
verse event.
Findings:
❚❚ A transition-of-care pharmacist is in a unique
position to education patients on hospital dis-
charge, to intercept a substantial number of
medication errors, and to resolve insurance is-
sues that may lead to adherence problems.
❚❚ These improvements in care may result in re-
duced hospital readmission rates.
444 JAPhA | 5 5:4 | JUL /AUG 2 0 1 5 ja p h a.org
ing hospital located in southern Arizona. No pharmacist
was solely dedicated to providing medication reconcili-
ation and education to patients being discharged from
the hospital before the addition of this transition-of-care
pharmacist. Before the implementation of this project,
medication reconciliation was primarily performed by
the discharging physician with discharge education
routinely provided by physicians and nursing staff.
This project was reviewed by a member of the Uni-
versity of Arizona Institutional Review Board and found
to be a quality improvement project, and approval was
received from the Department of Pharmacy Services,
Banner University Medical Center.
One transition-of-care pharmacist with residency
training and expertise in community and ambulatory
care practice was assigned to the project for the entire
evaluation. The pharmacist conducted the program on
two inpatient units (adult medical/surgical) with his-
torically high readmission rates. Eligible patients were
those who were discharged from either unit between
August 1, 2012, and July 3, 2013. One unit was a cardiac
step-down floor; most patients had recent cardiac sur-
gery or heart and lung transplant, or had heart failure.
The second unit was a lower acuity medicine–surgery
area with mixed patient populations, including those
on hemodialysis or peritoneal dialysis, those with end-
stage liver or renal disease, or those with infectious dis-
eases.
Approximately 60 patients on both units were dis-
cussed in daily care coordination rounds. The pharma-
cist was responsible for assisting with these patients at
discharge, but not all patients were seen by the pharma-
cist. Patients who were discharged between approxi-
mately 8:30 am to 5:00 pm on Monday through Friday
were included because of pharmacist availability; the
pharmacist also assisted in the discharge process outside
these hours if alerted ahead of time by the physicians or
nurses caring for the patient. In these cases, the pharma-
cist counseled these patients about medications before
discharge, coordinated receiving prescriptions from
physicians in advance to facilitate prior authorizations,
or filled and delivered medications to the nurse before
discharge. The pharmacist attended interdisciplinary
care coordination rounds daily with nurses, case man-
agers, and social workers to discuss barriers to patient
discharges and to assist in planning safe discharges.
For the first few months of the evaluation, the phar-
macist had to rely on other members of the medical team
for alerts of discharges. Starting in November 2012 the
pharmacist was subscribed to the discharge paging sys-
tem and was alerted when a discharge order was placed.
Because of this change, more patients were seen by the
pharmacist near the end of the evaluation period com-
pared with the beginning. Hospital policy states that pa-
tients should be out of the hospital within 2 hours of a
discharge, so the pharmacist did not have time to cover
Journal of the American Pharmacists Association

all discharge patients.
Before patient discharge, the pharmacist reviewed
patient information including insurance coverage,
medication adherence, and history and physical at ad-
mission. The pharmacist also verified with their outpa-
tient pharmacy, if needed, to determine if prescribed
medications would be covered or if there were any bar-
riers to dispensing medications at discharge. Once the
discharge order was placed, the pharmacist performed
medication reconciliation to identify and resolve dis-
crepancies. The pharmacist provided medication and
disease counseling to help improve adherence.
For patients not able to obtain their discharge medi-
cations at an outside pharmacy on the day of discharge,
the pharmacist facilitated the dispensing and delivery of
medications to the patient. The pharmacist made sure
patients were able to afford all prescriptions at discharge
and recommended generic alternatives when available.
Further, the pharmacist worked with the outpatient
pharmacy to waive patient copayments if the patient
could not afford them. For uninsured patients without
funds to pay for medications, the pharmacist worked to
obtain medications at no cost until case managers could
get the patients a low-cost clinic appointment. Nurses,
case managers, social workers, and outpatient pharma-
cy technicians assisted, when needed, in the discharge
process after problems were identified. The pharmacist
contacted patients to resolve problems not solved before
discharge. The pharmacist did not routinely call all pa-
tients after discharge.
The pharmacist tracked the number of patients who
were assisted with discharge, including those in need
of discharge counseling. The pharmacist also collected
information such as the type of intervention (action
taken to improve a situation) performed, medications
that required changes to ameliorate or prevent medi-
cation errors (any errors or mistakes occurring during
the medication-use process), and how much time was
spent interacting with each patient. The pharmacist did
not contact patients by telephone after discharge un-
less alerted to a discharge problem by a nurse or unless
a patient contacted the pharmacist after discharge with
a question or problem (pharmacist business cards were
given at discharge). For the purpose of comparison,
monthly hospital discharge and readmission rates dur-
ing discharge with pharmacist involvement were com-
pared with the previous year during which pharmacists
were not involved in discharge programs.
Data analysis
Data were initially entered into an Excel spreadsheet
for subsequent analysis using Stata 13.0 (StataCorp LP,
College Station, TX). Categorical comparisons were
performed using chi-square or Fisher’s exact test. Other
group comparisons were performed using the two-sam-
ple Wilcoxon rank-sum test. The level of significance
Journal of the American Pharmacists Association
TRANSITION-OF-CARE PHARMACIST EXPERIENCE
was set at P <0.05 for all analyses.
Results
During the evaluation period, 3,143 patients were dis-
charged from the two evaluation units of the hospital.
The discharge pharmacist coordinated a total of 1,058
discharges (33.7% of all patients discharged from these
units). The pharmacist was involved in the education
of 1,011 patients and performed interventions for 452
patients (44.7% of the patients). The pharmacist inter-
cepted 450 medication errors; 439 of these were prescrib-
ing errors made when the physician placed the order
(97.6%).
There was no difference in readmission rates per
month during the evaluation period between the two
inpatient units (P = 0.1656). There were more readmis-
sions per month (median 27.5 vs. 25, P = 0.0369) and dis-
charges per month (median 156.5 vs. 148, P = 0.0073) in
the previous control year versus the year of pharmacist
involvement.
Discharges coordinated by the pharmacist (n =
1,058) were often complicated with patients receiving
numerous medications—83.5% of patients were dis-
charged on 5 or more medications and 51.8% of patients
were discharged on 10 or more medications. Time spent
by the pharmacist resolving discharge issues were as
follows: less than 15 minutes (5.8%), 15 to 30 minutes
(19.1%), 30 to 60 minutes (38.8%), and more than 60 min-
utes (36.4%).
The pharmacist assisted in coordinating the insur-
ance benefits for 25% of the 1,058 patients being dis-
charged—this included getting prior authorizations and
prescribing less expensive medications the patient could
afford. Interventions made by the pharmacist to im-
prove discharge management are shown in Table 1. The
most common medication classes involved are listed in
Table 2. Examples of some specific and important inter-
ventions are listed in Table 3.
Discussion
This study demonstrates that a transition-of-care phar-
macist is in a unique position to educate patients on
hospital discharge, to reconcile medications and inter-
cept a substantial number of medication errors, and to
resolve insurance issues and other problems relative to
obtaining medications that may lead to adherence prob-
lems. In addition to reducing hospital readmission rates
compared with the previous control year, the pharma-
cist made interventions on 44.7% of patients seen before
discharge. Approximately 75% of these interventions
were to intercept problems (e.g., drug interactions, inap-
propriate or improper medication, therapeutic duplica-
tion, omitted medication, or multiple medication related
problems) that might have led to adverse drug events.
A similar evaluation at an academic medical center
found that most patients required intervention by the
j apha.org JU L/A U G 2015 | 55:4 | JAPhA 445
EXPERIENCE TRANSITION-OF-CARE PHARMACIST

pharmacist. Of 99 patients seen by the pharmacist at dis- Table 1. Interventions made by the pharmacist to improve discharge
charge, only 8 patients did not need pharmacy interven- management (n = 452)
tion; patients required an average of 9.4 interventions.9
Of note, patients in the latter evaluation were contacted Interventions (%)
by phone within 3 to 5 days of discharge to answer ques- Prevent a drug interaction 3.3
tions and ensure appropriate understanding of medica- Change a prescription for an inappropriate medication/
tions—telephone calls were not routinely performed in indication 5.1
our evaluation. Correct improper medication dose or quantity 11.3
According to a study conducted in an inner city Correct insurance issues related to medication coverage 12.2
hospital, only 40% of patients obtained their medica- Resolve other problems 12.6
tions the day of discharge. Having a pharmacist assist Avoid duplication of therapy 15.7
patients in obtaining their medications before discharge Perform more than one discharge intervention 16.4
or making sure they are able to obtain them the same Start an omitted medication 23.5
day of discharge can help to improve medication adher-
ence.10 One hospital screened for any potential barriers Table 2. Most common medication classes involved (n = 452)
to adherence when counseling patients at discharge and
found that 61% had a previous history of nonadher- Medication classes (%)
ence; of these patients, 35% stated that financial barriers Antihyperlipidemic agents 3.10
were the leading cause of nonadherence.6 Similar to our Antidepressant agents 0.22
findings, these studies demonstrate the importance of Opioid analgesics 3.33
having a pharmacist reconcile patient medication lists Beta-blocker agents 1.11
before discharge, coordinate prior authorizations, and ACEIs/ARBs 3.33
ensure patients can afford prescribed medications.
Antihyperglycemic agents 3.77
Our findings are consistent with other reports that
Respiratory agents 3.10
found medication discrepancies at discharge in 33.5%
to 80% of patients.2,3,11,12 Medication discrepancies can Gastrointestinal antiulcer agents 2.00
more than double the risk of readmission within 30 Diuretics 2.66
days.4 In addition to discharge counseling, results from Anticonvulsant agents 0.44
other investigations suggest that postdischarge follow- Hypnotic/sedatives 0.44
up telephone calls are another way to reduce hospital Thyroid agents 0.22
readmissions. One study at an academic medical center Calcium channel blockers 0.22
found that follow-up telephone calls within 14 days of Antimicrobial agents 9.09
discharge reduced readmission rates in patients who re-
Anticoagulant agents 7.98
ceived a pharmacist intervention before discharge.3 An-
Multiple medications 35.03
other study found a decrease in hospital readmissions
in high-risk patients who received a call from a pharma- Other medications not listed 23.95
cist 3 to 7 days after discharge for medication reconcili- Abbreviations used: ACEIs, angiotensin-converting enzyme inhibitors; ARBs,
angiotensin II receptor blockers.
ation. This study also found that 80% of the patients in
the study group had at least one medication discrepancy Limitations
at discharge.12 A study of patients with high-risk heart This project had several limitations including the fact
failure found a decrease in hospital readmissions over that the pharmacist was only able to interact with 33.7%
12 months for heart failure from 59% to 24% in an inter- of patients discharged from the two units under evalu-
vention group of patients who received education and ation. When multiple discharges occurred at the same
medication reconciliation from a pharmacist.13 Whether time, the pharmacist saw the more complex patients
routine follow-up calls would have further decreased identified in care rounds.
readmissions in our evaluation is unknown since the The data for readmission and discharges were for all
pharmacist did not routinely perform this function. patients discharged from the evaluation floors, includ-
In terms of the types of medication involved in med- ing those with no pharmacist involvement.
ication errors, the findings of our evaluation are simi- It is not possible to conclude that the pharmacist
lar to those from previous evaluations. For example, a was the only reason for the decrease in readmissions
study involving an academic medical center found that compared with the historical control period without the
the most common drug classes involved were antibiot- transition-of-care pharmacist given that the pharmacist
ics, corticosteroids, cardiovascular drugs, analgesics, was not able to provide direct care for all patients on the
and anticoagulants.14 floors.
There are other potential and unaccounted for con-
founders including the number of discharges relative

446 JAPhA | 5 5:4 | JUL /AUG 2 0 1 5 ja p h a.org Journal of the American Pharmacists Association
 TRANSITION-OF-CARE PHARMACIST EXPERIENCE

Table 3. Examples of specific interventions and problems solved by the discharge pharmacist
Interventions
Allergies
Existing allergy information
Add/change/delete medication
Duplicate therapy
Missing medication
Missing prescription
Improper medication selection
Drug interaction
Contraindicated medication
Medication without indication
Improper dosage form
Dosing
Inappropriate dosing
Cost
Nonformulary/insurance issue
Patient cannot afford original medi-
cation ordered
Other
Missing follow-up
Missing medical supplies
Examples
Patient with allergy to Ibuprofen given medication at discharge. Changed to tramadol.
Patient with a preexisting allergy to losartan prescribed losartan as a new medication at discharge. Medication
discontinued.
Patient prescribed both home simvastatin and hospital pravastatin at discharge. Home medication resumed.
On home lisinopril 20 mg daily but in hospital lisinopril was increased to 40 mg daily for discharge. New dose
included on discharge.
Furosemide not restarted in heart failure patient at discharge. Added medication to discharge.
Hospital discharge on a fondaparinux bridge but missing a prescription for warfarin. New prescription written.
Prescriptions missing for new medications started in the hospital; home medications patient was out of and not
taking. New prescriptions written.
New insulin prescribed at discharge but missing prescriptions for syringes and testing supplies. New prescrip-
tions written.
Antibiotic changed to oral cephalexin at discharge but cultures showed resistance. Changed to ciprofloxacin.
Oral sulfamethoxazole/trimethoprim started at discharge but no dosage adjustment made to warfarin. Decreased
warfarin dose and INR appointment scheduled.
Home simvastatin restarted on patient with Helicobacter pylori on clarithromycin. Simvastatin held during antibi-
otic therapy.
Furosemide discontinued at discharge but potassium continued. Potassium discontinued.
Home diltiazem extended-release capsule prescribed at discharge but could not be given with new J tube.
Changed to immediate release that had been given in hospital.
Laboratory tests came back elevated at discharge and warfarin not adjusted. Warfarin dose decreased.
Moxifloxacin not covered by insurance; changed to levofloxacin.
Provided inexpensive medication at no charge for uninsured patient so patient could take medications until
scheduled low-cost clinic follow up.
Reduced cost of clopidogrel so patient could afford to take for 1 year after stent.
New start warfarin patient discharged without laboratory follow-up.
Patient discharged on new albuterol nebulizer vials but missing a home nebulizer machine. Prescription written
for nebulizer machine and dispensed by hospital before discharge.

to readmissions and potential overlap of some read-
missions occurring during the control and intervention
year.
Lessons learned
It was very difficult to start out a new service and get all
the members of the health care team to accept this new
role for pharmacists. Each time a nurse or physician was
assisted by the discharge pharmacist with a difficult
discharge, trust was earned and reputations enhanced
through word of mouth about the benefit of the service.
The difficult part of this service was being alerted
when a patient was being discharged to perform dis-
charge medication reconciliation. The pager system
worked for discharges, but many times multiple pages
were received at the same time.
A better system might be to have a pharmacist rec-
oncile medication within 24 hours after discharge and
follow up with the patient by telephone to resolved
discrepancies and make sure all medications were ob-
tained; using such an approach, all patients discharged
would receive services.
Another option might be to have the discharge held
until a pharmacist evaluates discharge medications for
accuracy and completeness; this might be difficult for
early or late discharges.
In future projects that involve readmission rates, a
key need is ready access to timely and accurate readmis-
sion rates of patients cared for by the pharmacist versus
patients in other comparator groups (e.g., historical con-
trol, patients on a similar unit, comparable group of pa-
tients not seen by the pharmacist).
Conclusion
A transition-of-care pharmacist is in a unique position
to educate patients on hospital discharge, to intercept a
substantial number of medication errors, and to resolve
insurance issues that may lead to adherence problems.

Journal of the American Pharmacists Association j apha.org JU L/A U G 2015 | 55:4 | JAPhA 447
EXPERIENCE TRANSITION-OF-CARE PHARMACIST
These improvements in care may result in reduced hos-
pital readmission rates.
There are ongoing attempts in our hospital to ensure
that all patients discharged with medications have pre-
discharge reconciliation performed by a pharmacist or
supportive personnel under the supervision of a phar-
macist. Additional studies are needed to determine the
most cost-effective way to provide pharmacist involve-
ment in medication reconciliation and assistance with
making sure patients obtain their medications at dis-
charge.
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