Over the last year Transitions of Care (ToC) has become a focus at many conferences and part of healthcare conversations; this year’s American Society of Health-System Pharmacists (ASHP) Midyear meeting was no different. A topic at this gathering of pharmacists, most of who work in hospitals, was the challenges surrounding patient discharge. Included was ensuring that patients are discharged with the correct medications, that they get their new scripts filled once they are discharged, and most importantly, that they go see their physician outside of the hospital.
There are many programs in place that are supposed to assist in this ToC process. However, there are so many stakeholders involved in patient care and so many permutations of care for patients, that this process is quite complex. In the hospital, nurses, physicians, pharmacists, social workers, discharge personnel and case workers typically interact with patients. Who among these healthcare providers are responsible for making sure patients have the correct medications, paperwork, and education at the time of discharge? If one of these stakeholders is not available or does not have the required time to spend with the patient at time of discharge, what gets lost and what is the result? Generally, the patient ends up without the appropriate tools, or confused and frustrated with the lack of post-hospital direction.
All these stakeholders are working to improve the patient experience, however, there have not been any programs developed that have completely removed all barriers to a smooth transition of care. Many of the pilot ToC programs are now reviewing results and hopefully we will be able to gain some best practices from those taking place at institutions like Mass General and The Cleveland Clinic. More to come in the next year!