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Toolkit: Transitions of Care Management Transitional References

Pharmacist-Specific References/Resources


ASHP-APhA Medication Management in Care Transitions Best Practices


This document produced by ASHP and APhA solicited best practices from over 80 submissions in 2012, eventually including 8 programs.  All these "best practices" have a pharmacy services built into the transitional care model.  The report also identifies elements for the success of transitional car models and common barriers encountered.


Systematic review of pharmacists role in care transitions


This systematic review compiled 30 studies through November 2014 into a systematic review, assessing the benefit of different types of pharmacy-based interventions on post-discharge outcomes.  The review suggested evidence to support medication reconciliation, active patient counseling, and a clinical medication review along with post-discharge coordination and integration of pharmacists in ambulatory/community settings armed with pertinent clinical information.


Transitions of Care Case Examples Resource


For APhA members, this resource provides case examples of transitional care patients from the viewpoint of pharmacists in various practice settings.


NCPA Transitions of Care Toolkit


This member-only toolkit is available through NCPA and provides a community-pharmacist view on how to deliver transitions of care programs and how to stand them up.  They provide a how-to approach a community hospital about collaboration, and the resources recommended to get care developed.  A webinar highlighting a transitions program in Seattle is also included.


University of Hawaii, Pharm2Pharm

An online 6 hour CE course, the University of Hawaii Transitions course is based upon the Pharm2Pharm transitional educational course.  There is a fee to complete the course.



General Transitions of Care Resources


National Transitions of Care Coalition


This resource provides a collection of resources, including research articles, consensus documents and patient educational information and could be used by policy makers, pharmacists (and other healthcare professionals) and patients.  Some of the information on this website is a bit dated, but much of it is helpful for those on the front line and those thinking about starting up a transitions program.


Joint Commission Transitions of Care (ToC) Portal


This website provides a multi-media compilation of resources around transitions of care from videos on transitioning patients, to guidance on improving communications during the transitional care process.  They specifically highlight the "Hand-off Communication Project" that is meant to limit errors and issues that happen with incomplete or poor communication when patients are "handed off" from one provider (or system) to another.  Signing up for the videos is very easy, and provides some great overviews of the problems associated with transitional care and has one specifically written on "challenges in medication management".


Agency for Healthcare Research and Quality (AHRQ), Medications at Transitions and Clinical Handoffs (MATCH) Toolkit


Specifically devoted to medication-related care within the transitional environment (i.e. hospital to home), this resource in the public domain and supported by AHRQ contains the "how to" in getting a comprehensive transitional care program together that includes leadership engagement, project team development, medication reconciliation best practices, pilot testing, education and assessment.

Click here for this resource


MProject RED (Re-Engineered Discharge)

http://www.bu.edu/fammed/projectred/, https://www.ahrq.gov/professionals/systems/hospital/red/toolkit/index.html

Developed by a research group at Boston University Medical Center and sponsored by AHRQ, Project-RED is a robust transitional care program and plan aimed at improving patient safety during transitions with the goal of reducing readmissions. Project-RED features a 12-component intervention. A novel part about this project and website, with accompanying discharge toolkit, is the virtual patient advocate names "Louise" that walks though how to provide care to patients being discharged.  Also, this program was originally tested with pharmacists as part of the discharge process, and although this has been rolled out at other places, not all of the other hospitals have maintained pharmacist participation in the team.

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Hospital-to-Home (H2H) by the American College of Cardiology Quality Improvement for Institutions


A transition program designed primarily for hospitals and cardiovascular providers to assist the transitions of patients and reduce readmissions.  They recommend specifically a follow-up appointment within 7 days of discharge with a provider (H2H SY7), education on signs and symptoms of post-discharge problems (H2H S&S), and a section on optimizing medications (H2H MM).  Some content requires login information, but sign-up is free and easy.


State Action on Avoidable Rehospitalizations (STAAR)


A program funded by the Commonwealth Fund, STAAR was designed to provide the foundation to reduce avoidable rehospitalizations on a State-wide basis.  Used in Massechusetts, Michigan, and Washington, this initiative provides exceptional insights on the transitional care process and recommends interventions to reduce preventable rehospitalizations. STAAR provides guidance on areas for improvement and metrics to measure when instituting a transitional care initiative.


StepsForward model in transitions of care from the AMA and University of Tennessee


Provides a CME-based short curriculum on a transitional care model through March 2019.  Materials are available for free from the website.


Transitions of Care Consensus Conference

Consensus group outlining principles/standards for transitioning patients from hospital to home.  The document does have a list of components that should be transmitted with the patient upon discharge (this list would be helpful in dialogues with hospitals on elements useful to community pharmacists caring for patients post-discharge).  This list includes: 1) Principal diagnosis, 2) Medication list (reconciled), 3) Emergency contact, 4) Treatment plan, 5) Labs and other test results, 6) transferring physician/institution, 7) patient's cognitive status, 8)advanced directives and consent, 9) planned interventions and follow-up, 10) Caregiver status/information.

-Journal of Hospital Medicine 2009;4:364–370.

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