title: Implementation of transitions-of-care services through acute care and outpatient pharmacy collaboration.
abstract: OBJECTIVE
  The implementation of a practice model designed to reduce hospital readmissions through optimal deployment of pharmacy staff on multidisciplinary care collaboration teams is described.
  
  
  CONCLUSIONS
  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.
  
  
  CONCLUSIONS
  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.
authors: Vi Gilmore, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; Leigh Efird, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Denise Fu, Pharm.D., BCACP, is Clinical Coordinator, Johns Hopkins Home Care Group, The Johns Hopkins Hospital, Baltimore, MD. Yvonne LeBlanc, Pharm.D., M.B.A., is Inpatient Pharmacist, Lahey Hospital and Medical Center, Burlington, MA; at the time of writing, she was Outpatient Clinical Programs Manager, Johns Hopkins Home Care Group. Todd Nesbit, Pharm.D., M.B.A., is Associate Director, Decentralized and Clinical Services, The Johns Hopkins Hospital. Meghan Swarthout, Pharm.D., M.B.A., BCPS, is Division Director, Ambulatory and Care Transitions, The Johns Hopkins Hospital, and Associate Director, Clinical Services, Johns Hopkins Outpatient Pharmacy, Johns Hopkins Home Care Group. vdo1@jhmi.edu.
authors: Vi
authors: V
authors: Gilmore
authors: Vi Gilmore, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; Leigh Efird, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Denise Fu, Pharm.D., BCACP, is Clinical Coordinator, Johns Hopkins Home Care Group, The Johns Hopkins Hospital, Baltimore, MD. Yvonne LeBlanc, Pharm.D., M.B.A., is Inpatient Pharmacist, Lahey Hospital and Medical Center, Burlington, MA; at the time of writing, she was Outpatient Clinical Programs Manager, Johns Hopkins Home Care Group. Todd Nesbit, Pharm.D., M.B.A., is Associate Director, Decentralized and Clinical Services, The Johns Hopkins Hospital. Meghan Swarthout, Pharm.D., M.B.A., BCPS, is Division Director, Ambulatory and Care Transitions, The Johns Hopkins Hospital, and Associate Director, Clinical Services, Johns Hopkins Outpatient Pharmacy, Johns Hopkins Home Care Group.
authors: Leigh
authors: L
authors: Efird
authors: Vi Gilmore, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; Leigh Efird, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Denise Fu, Pharm.D., BCACP, is Clinical Coordinator, Johns Hopkins Home Care Group, The Johns Hopkins Hospital, Baltimore, MD. Yvonne LeBlanc, Pharm.D., M.B.A., is Inpatient Pharmacist, Lahey Hospital and Medical Center, Burlington, MA; at the time of writing, she was Outpatient Clinical Programs Manager, Johns Hopkins Home Care Group. Todd Nesbit, Pharm.D., M.B.A., is Associate Director, Decentralized and Clinical Services, The Johns Hopkins Hospital. Meghan Swarthout, Pharm.D., M.B.A., BCPS, is Division Director, Ambulatory and Care Transitions, The Johns Hopkins Hospital, and Associate Director, Clinical Services, Johns Hopkins Outpatient Pharmacy, Johns Hopkins Home Care Group.
authors: Denise
authors: D
authors: Fu
authors: Vi Gilmore, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; Leigh Efird, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Denise Fu, Pharm.D., BCACP, is Clinical Coordinator, Johns Hopkins Home Care Group, The Johns Hopkins Hospital, Baltimore, MD. Yvonne LeBlanc, Pharm.D., M.B.A., is Inpatient Pharmacist, Lahey Hospital and Medical Center, Burlington, MA; at the time of writing, she was Outpatient Clinical Programs Manager, Johns Hopkins Home Care Group. Todd Nesbit, Pharm.D., M.B.A., is Associate Director, Decentralized and Clinical Services, The Johns Hopkins Hospital. Meghan Swarthout, Pharm.D., M.B.A., BCPS, is Division Director, Ambulatory and Care Transitions, The Johns Hopkins Hospital, and Associate Director, Clinical Services, Johns Hopkins Outpatient Pharmacy, Johns Hopkins Home Care Group.
authors: Yvonne
authors: Y
authors: LeBlanc
authors: Vi Gilmore, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; Leigh Efird, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Denise Fu, Pharm.D., BCACP, is Clinical Coordinator, Johns Hopkins Home Care Group, The Johns Hopkins Hospital, Baltimore, MD. Yvonne LeBlanc, Pharm.D., M.B.A., is Inpatient Pharmacist, Lahey Hospital and Medical Center, Burlington, MA; at the time of writing, she was Outpatient Clinical Programs Manager, Johns Hopkins Home Care Group. Todd Nesbit, Pharm.D., M.B.A., is Associate Director, Decentralized and Clinical Services, The Johns Hopkins Hospital. Meghan Swarthout, Pharm.D., M.B.A., BCPS, is Division Director, Ambulatory and Care Transitions, The Johns Hopkins Hospital, and Associate Director, Clinical Services, Johns Hopkins Outpatient Pharmacy, Johns Hopkins Home Care Group.
authors: Todd
authors: T
authors: Nesbit
authors: Vi Gilmore, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; Leigh Efird, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Denise Fu, Pharm.D., BCACP, is Clinical Coordinator, Johns Hopkins Home Care Group, The Johns Hopkins Hospital, Baltimore, MD. Yvonne LeBlanc, Pharm.D., M.B.A., is Inpatient Pharmacist, Lahey Hospital and Medical Center, Burlington, MA; at the time of writing, she was Outpatient Clinical Programs Manager, Johns Hopkins Home Care Group. Todd Nesbit, Pharm.D., M.B.A., is Associate Director, Decentralized and Clinical Services, The Johns Hopkins Hospital. Meghan Swarthout, Pharm.D., M.B.A., BCPS, is Division Director, Ambulatory and Care Transitions, The Johns Hopkins Hospital, and Associate Director, Clinical Services, Johns Hopkins Outpatient Pharmacy, Johns Hopkins Home Care Group.
authors: Meghan
authors: M
authors: Swarthout
mesh_terms: D000553:Ambulatory Care / Q000458:organization & administration*; D003266:Continuity of Patient Care / Q000458:organization & administration*; D003299:Cooperative Behavior; D006801:Humans; D017146:Models, Organizational; D010348:Patient Care Team / Q000458:organization & administration*; D058991:Patient Protection and Affordable Care Act; D010359:Patient Readmission; D010595:Pharmacists / Q000458:organization & administration; D010607:Pharmacy Service, Hospital / Q000458:organization & administration*; D014481:United States