MPA | Pharmacy News

Amber Lanae Martirosov, Pharm.D., BCPS
Clinical Pharmacy Specialist, Ambulatory Care, 
Henry Ford Health Systems
Clinical Assistant Professor, Department of Pharmacy Practice
Eugene Applebaum College of Pharmacy and Health Sciences Wayne State University

In 2013, the Centers for Medicare and Medicaid Services instituted a penalty for hospital readmissions. This motivated health systems throughout the United States to transform their discharge processes and improve 30-day readmission rates.6,7  Across the country, pharmacists serve as valuable members of the interdisciplinary team and demonstrate significant impacts on financial and patient outcomes, including transitions of care (TOC) interventions.1 Pharmacy-driven TOC programs include, but are not limited to, medication reconciliation. The impact of pharmacist-driven medication reconciliation has been highlighted by the Joint Commission and benchmarked as a national safety goal to prevent adverse drug events.4 Other successful TOC programs include interventions that are classified based on pre-discharge, post-discharge and bridging (See Table 1). The purpose of this article is to provide guidance on developing pharmacy-driven TOC services and highlight TOC services across Michigan.

Pharmacists can serve to make key TOC services within a multi-disciplinary approach or can develop pharmacy-driven TOC services. Table 1 highlights TOC best practices evaluated in pharmacy literature. The fundamental component of a successful TOC program requires preparing a business plan with attainable and measurable goals. Many considerations need to be made including identifying a patient population, determining how patients will be referred and allocating the appropriate amount of time for TOC activities. Additionally, programs must have clear lines of communication between the healthcare team, a proper process for documentation, a plan to demonstrate benefit or value, specific staffing responsibilities and consideration of financial resources.3

An important aspect of developing a TOC service is having proper staffing with defined roles. A great example of defining roles is at Johns Hopkins Medicine. This TOC model consists of a pharmacist team leader with residents, students and technicians supporting the workflow. Technicians and students enter referral orders, perform medication history interviews, contact community pharmacies for prescription history and deliver medications to patients at bedside before discharge. This allows for the pharmacist to focus their time attending multidisciplinary rounds, providing patient education and optimizing therapy with medication reconciliation.2,3

One of the main barriers to establishing any new service is demonstrating a financial benefit to the healthcare system. The costs associated with allocating new staff and resources must be offset by cost savings and potential revenue. Ni and colleagues performed a budget impact analysis by modeling a TOC service from Kern Health System in California. Over six months, the TOC service reduced readmissions by 32 percent and saved the health plan $2,139 per patient referred to the program (approximately $4.3 million in total healthcare costs). The average cost of the service was $99 per patient.5 In addition to cost savings from a TOC service, pharmacists can also help obtain direct revenue opportunities to the health system through billing TOC codes. Billing codes introduced in 2013 allow for billing incident-to physician transitions of care management.1 Table 2 details the rules for TOC billing and highlights where pharmacists can have an impact.

Many practice sites in Michigan including Detroit Medical Center, Henry Ford, Muskegon Health and University of Michigan have been recognized as best practice winners for their pharmacist-led TOC models. Consider evaluating these programs or reaching out to the pharmacy departments at these sites for more guidance on preparing successful programs. Additionally, Figure 1 provides step-wise considerations for creating a TOC service in your institution. With these tools and guidance from best practice winners, Michigan pharmacists have the opportunity to become national leaders in transitions of care services.
Table 1: Best Practices for Successful TOC Programs
Pre-Discharge Interventions
  • Identifying patients at risk for adverse events or readmissions
  • Proving patient education and patient friendly informational handouts
  • Creating a specific TOC patient documentation record
  • Communicating with outpatient providers and pharmacists
  • Being part of a multidisciplinary discharge team
  • Performing medication reconciliation
  • Ability for inpatient providers to view outpatient notes
  • Pharmacists, residents, students, and technicians have defined and complimentary roles

Post-Discharge Interventions
  • Following up with patients via phone-call, clinic visits, or home visits
  • Ability for outpatient providers to view inpatient notes
  • Documentation of outcomes including improved HCAHPS score, reduced readmissions and sustained positive impact on patient care
  • Documentation of financial impact and return on investment
  • Pharmacists, residents, students, and technicians have defined and complimentary roles
  • Established ways to provide patients with assistance programs when needed

Bridging Interventions
  • Referring patients to services through multiple outlets
Billing Codes
Practice Setting
2017 Medicare Payment
99496 (within 7 days)
Physician-based (PB) and hospital-based (HB)
  • $236.53 (PB)
  • $165.33 (HB)
99495 (within 14 days)
  • $167.15 (PB)
  • $114.10 (HB)
Several complex requirements including:
  • Patient established with billing provider
  • Interactive communication within two business days
  • Face-to-face visits within 14 calendar days (Must be with MD, DO, NP, CNP, PA, certified nurse midwife)
*Claim date must be 30 days from discharge. If patient readmitted before 30 days, TCM claim not reimbursable
Pharmacist Role:
Non-face-to-face component: Phone call within two days of discharge
  • Medication reconciliation
  • Disease-state education
  • Schedule appointment within seven or 14 days
  • Triage urgent needs
Face-to-Face Component:
  • Discuss medication-related issues with the team
  • Provide medication reconciliation and disease- state education
  • Develop a plan with the team


  1. Spike TOC, Pope BDD, Vanlandingham M. Teed Up for a TOC Spike. 2013;(September):32-5.
  2. Malacos K. Pharmacy technicians in transitions of care. Pharm Times [Internet]. 2016;82(5):3-5. Available from:
  3. Cassano A. Best Practices from the ASHP-APhA Medication Management in Care Transitions Initiative. 2013.
  4. Alex S, Adenew A, Arundel C, Maron D, Kerns J. Medication Errors Despite Using Electronic Health Records: The Value of a Clinical Pharmacist Service in Reducing Discharge-Related Medication Errors. Q Manag Heal Care. 2016;25(1):32-7.
  5. Ni W, Colayco D, Hashimoto J, Komoto K, Gowda C, Wearda B, et al. Budget Impact Analysis of a Pharmacist-Provided Transition of Care Program. J Manag Care Spec Pharm [Internet]. 2018;24(2):90-6. Available from:
  6. Rennke S, Ranji SR. Transitional Care Strategies From Hospital to Home: A Review for the Neurohospitalist. The Neurohospitalist. 2015;5(1):35-42.
  7. Hospital Readmissions Reduction Program (HRRP) Archives [Internet]. Services, Centers for Medicare & Medicaid. 2018. Available from:

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