Transition of Care


June 19, 2017

transitions-of-care-home-health

“It all started with pain radiating down my left arm. It was hard to breathe and I was short of breath. I knew something was wrong and called 911. I was rushed to the hospital. I remember the sirens, but they slowly faded away. Then I woke up. There was a man in a white coat telling me that I’d had a heart attack. He handed me some medicine bottles and prescriptions. Before you know it, I was discharged and on my way home.”

This was how Nancy described her heart attack. After several days in the hospital,  Nancy was discharged home, and now has to take four new medications every day. That can add up to a lot of out-of-pocket expense.

This scenario happens all too often, and through an unfortunate set of events, Nancy was re-admitted into the hospital just three weeks later.

Moving Through the Healthcare System

Transition of Care (TOC) is the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.1 This definition by The Centers for Medicare & Medicaid Services (CMS) describes the process of a patient navigating the health care system and the unfortunate, but common reality that gaps in care develop between the hospital and outpatient setting.

A Growing Healthcare Need

This area of healthcare is expanding and becoming more important to help reduce readmission rates and the cost of healthcare. Pharmacists are expanding their roles by providing TOC services to patients newly diagnosed with specific conditions and/or a flare-up of a chronic condition or disease. Quite often will a patient’s medication therapy change upon admittance to a hospital and then at discharge from the hospital. They may be prescribed new medications after a hospital stay. The goal is to ensure the continuity of care for patient and help fill the gap, by:

  • Providing education about a condition
  • Monitoring a condition
  • Helping patients understand their medication.

Why Transition of Care Matters

Helping patients understand their prescription medications allows them to get the most benefit from them, and, to understand why it is important to take their medications as prescribed. Helping patients save on prescription medication costs is what ScriptSave WellRx does.

It is not just pharmacists that are expanding into this role, but other health care professionals like nurses, doctors, and case managers, too. It takes a care team effort and patient-centric approach to ensure that each patient is getting the best, high-quality care available.

 

References:

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/8_Transition_of_Care_Summary.pdf


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