Implementation of transitions-of-care services through acute care and outpatient pharmacy collaboration Journal Articles uri icon

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  • PURPOSE: The implementation of a practice model designed to reduce hospital readmissions through optimal deployment of pharmacy staff on multidisciplinary care collaboration teams is described. SUMMARY: In response to Affordable Care Act provisions aimed at reducing preventable hospital readmissions, the pharmacy department at The Johns Hopkins Hospital (JHH) led the implementation of a new pharmacy services model spanning both inpatient and outpatient settings. Key components of the model include (1) increased pharmacist participation in multidisciplinary rounds, (2) targeted medication reconciliation and patient education, (3) postdischarge phone monitoring of selected patients, and (4) bedside discharge medication delivery performed by a "transitions pharmacist extender." Incorporation of care coordination activities into the daily workflow has increased the rate of patient education on high-risk medications and allowed for affordable and effective medication regimens to be designed and prescriptions to be filled prior to patient discharge. The ultimate goal is enhanced multidisciplinary collaboration to decrease hospital readmissions by increasing medication adherence and patients' understanding of medications. CONCLUSION: The inpatient and outpatient pharmacy teams at JHH collaborated to improve their understanding of patients' medication use prior to admission through targeted medication reconciliation, education of patients on high-risk medications initiated during admission, and development of affordable and practical medication regimens that patients would receive in hand on discharge. A pharmacy team model was developed to ensure that these services are adequately provided and enhance patient understanding of the importance of medications for acute and chronic disease state management.


  • Gilmore, Vi
  • Efird, Leigh
  • Fu, Denise
  • Leblanc, Yvonne
  • Nesbit, Todd
  • Swarthout, Meghan

publication date

  • May 1, 2015