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Improving Care Transitions of Hospitalized Patients With the Pharmacy Integrated Transitions Program

Improving Care Transitions of Hospitalized Patients With the Pharmacy Integrated Transitions Program

Standardizing the hospital-to-skilled nursing facility transition by using a structured handoff between clinical teams along with a pharmacist to monitor patient medications during the transition may improve care coordination and communication, and reduce medication-related problems for patients.

Principal Investigator: Davidson, Giana
Organization: University of Washington
Research Profile: Preventing Medication-Related Problems in Care Transitions to Skilled Nursing Facilities
Funded Amount: $2,000,000

A safe and smooth transition to skilled nursing facilities

The transition of patient care from hospitals to skilled nursing facilities (SNFs) is a complex process, presenting challenges that expose the most vulnerable patients to a high risk of complications, emotional distress, and hospital readmissions. The lack of coordination and effective communication tools between medical professionals at each facility is a significant issue throughout care transitions, which can lead to medication-related problems, and complications that can lead to preventable hospital readmission. As a general surgeon and health services researcher, Dr. Giana Davidson recognized the disconnect in expectations among providers and patients on their care journey, especially for the most vulnerable patients transitioning to SNFs. She wants to improve the care coordination and communication throughout the transition process to ensure patient safety and comfort.

Following the road to recovery

The Pharmacy Integrated Transitions (PIT) program was developed by Dr. Davidson and her University of Washington-based team to standardize the transition process by utilizing an added resource of a pharmacy-led integrated transition team who will implement a structured warm handoff and collaborate with the hospital and SNF teams to provide comprehensive support regarding medication management during care transitions. The PIT program integrates a warm handoff tool for the clinical teams at the hospital and the SNF, including an option for using teleconferencing technology. The program also requires an expanded role for hospital-based pharmacists to reconcile medications at hospital discharge, along with providing teleconference communication to the SNF clinical team and medication monitoring during the transitional period. New funding from the Agency for Healthcare Research and Quality will fund research to test the effectiveness of the PIT program on reducing medication-related problems during the transition period, while also monitoring patient- and caregiver-reported quality of care throughout the process.

Our hope is that we will see a significant decrease in medication-related problems, and also the downstream consequences of those problems—that people will recover, require less time in SNFs, that they get back to their baseline function, that they will participate more in rehab, that they won’t get readmitted to the hospital… and that patients will be more satisfied with their care.”
-Dr. Davidson

Measuring inequities in SNF transition processes to improve care

The PIT program has the potential to provide big impacts to patient care and how we think about care transitional processes. Dr. Davidson is anticipating the program will decrease medication-related problems and improve overall patient safety during the transitional period of care from hospitals to SNFs. The research team will also measure equity within the program’s implementation, observing how people from different racial backgrounds, those who do not speak English, and people who are on high-risk medications are managed in the transitional process, thus exposing potential prescribing inequities. The PIT program shows promise to reduce hospital readmissions, lessen patient emotional distress by proactively addressing medication safety, and further reveal areas of improvement to advance healthcare equity within the SNF transition process.