MPA | Pharmacy News

By Matthew Enell, Pharm.D., clinical informatics pharmacist, Michigan Medicine, Ann Arbor


Transitions of care (TOC) occur when a patient moves from one level of care to another. These transitions can be complicated and patients are at a higher risk for medication errors. The Centers for Medicare and Medicaid services estimates that one in five Medicare patient discharges (about 2.6 million patients) are readmitted within 30 days, at a cost of over $26 billion every year.1


Pharmacists can play a key role in decreasing medication errors and help to prevent hospital readmissions. In a study conducted at Hennepin County Medical Center, they found that pharmacists on their TOC team helped to reduce readmission rates from a baseline of 23 percent to eight percent.2


Here at Michigan Medicine, we have established a number of different transitions of care initiatives to help better serve our patients. Our TOC team, composed of pharmacy technicians and pharmacists, works to identify and resolve medication access barriers including assisting with obtaining prior authorizations, co-pay checks to ensure patients can afford their medications and bedside delivery of discharge medications to help facilitate discharge. From an informatics perspective, our informatics team has worked with the TOC team to identify opportunities in the EHR to streamline their workflow. These include patient lists identifying patients with an upcoming discharge and/or medications that often require a prior authorization, automated pages to the TOC team when a patient has a discharge order and prescriptions to be filled by our ambulatory pharmacy and tools to communicate prior authorization statuses to other team members.


Another program that we have implemented is our LACE (Length of stay, Acuity of admission, Comorbidities, Emergency department visits) Initiative. This is a scoring tool within our electronic health record that is used to identify patients that are at a high risk of readmission or death within 30 days of discharge. A LACE score is auto-calculated throughout a patient’s stay, and it predicts if a patient is at a low, medium or high risk of readmission. The LACE score can be found in our patient lists, reports and the discharge summary and is color coded to easily identify high risk patients at a glance. High risk patients then receive an inpatient care manager evaluation and are provided bedside pharmacist discharge medication education. After the patient is discharged, a TOC pharmacist will obtain a medication history, perform medication reconciliation, complete a comprehensive medication review (via a phone call with patient), and document any recommendations that providers should follow-up on during the post-discharge primary care provider appointment.


As the number of transitions of care activities continue to grow, the tools we can provide within the electronic health record will become even more important to our care teams as they work to assist our patients through these complicated transitions. What have you done to address transitions of care issues at your institution?  Please share at our Michigan Society of Health-System Pharmacists Google Group Listserve or email



1.       Centers for Medicare and Medicaid Services. Community-Based Care Transitions Program Fact Sheet. CMS website.

2.       American Society of Health-System Pharmacists. ASHP-APhA Medication Management in Care Transitions Best Practices. ASHP website. February 2013.


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