Article contributed by AAPACN Solution Provider Synchrony Pharmacy
By Mandi Seay, Doctorate of Pharmacy Candidate, Class of 2026, Butler University
Defining Transitions of Care
Transitions of care (TOC) are nothing new to those working in long-term care. Every nurse in this setting has seen the challenges that come with moving a patient from the hospital to the skilled nursing facility, or from one care environment to another. Each step introduces opportunities for communication lapses, incomplete documentation, and fragmented medication management.
The Agency for Healthcare Research and Quality defines transitional care as “a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location.” This often means welcoming patients who arrive with a mix of new prescriptions, dose adjustments, discontinued therapies, and instructions that may be incomplete or unclear. For LTC nurses, these situations are familiar, and they are exactly when careful coordination can make the greatest difference and benefit the patient.
Why Transitions Are High Risk
Transitions of care are particularly vulnerable to errors because of the inherent complexity involved in managing medications during these periods. This complexity can give rise to several high-risk factors, including:
- Medication errors: These may involve missing or duplicate prescriptions, unintended changes, or incorrect drug, dose, or frequency, all of which can occur if discharge orders are not carefully reviewed.
- Adverse drug events (ADEs): Preventable harm resulting from inappropriate or unsafe medication use.
- Preventable hospital readmissions: Often linked to unresolved medication-related issues that carry over from one care setting to another.
The Pharmacist’s Emerging Role
Pharmacists are uniquely positioned to help reduce the risks that come with care transitions. As medication experts, they play a critical role in maintaining prescribing accuracy, supporting adherence, and serving as a vital link between providers, patients, and caregivers.
Their impact can be seen through a variety of interventions, such as medication reconciliation at key points in care, clear and timely communication with the healthcare team, and follow-up to address emerging concerns after transfer. These are just a few examples, and there are many other ways pharmacists can contribute depending on the needs of the patient and the care environment.
Impact on Outcomes
Pharmacist-led transitions-of-care programs have consistently shown meaningful improvements in patient outcomes, particularly in reducing avoidable hospital readmissions. In the BayCare Health System program, early pilot efforts integrating pharmacists into discharge medication reconciliation and follow-up led to a marked drop in 30-day readmissions. Rates fell from 15.9% to 9.0%, reflecting a substantial reduction in risk for patients leaving the hospital. When the model expanded across the system, these benefits persisted, with data showing that patients receiving pharmacist interventions were significantly less likely to return within a month compared to those who did not. In fact, when both medication reconciliation and post-discharge calls were completed, the observed-to-expected readmission ratio improved to 0.77, signaling a powerful effect on keeping patients safely at home. This impact was supported by strong collaboration with prescribers, who accepted nearly all pharmacist recommendations.
The benefits extend beyond readmission prevention. A separate study published in Hospital Pharmacy found that one in four patients had a clinically significant medication discrepancy identified by a pharmacist at discharge. These discrepancies ranged from omitted prescriptions to incorrect dosing and occurred across all patient subgroups, regardless of when admission medication histories were completed, how many medication changes occurred during the stay, or how often patients changed care units. This finding reinforces the idea that pharmacist review is valuable for all patients, not only those considered high risk.
Synchrony Rx@HOME adds another dimension to these positive outcomes. By following patients’ home after discharge, especially those leaving skilled nursing facilities, the service helps maintain continuity of care and supports adherence. Measured by Proportion of Days Covered (PDC), Synchrony’s patients consistently remain well above the 80% adherence threshold considered necessary for clinical effectiveness. Synchrony ArrivalRX further strengthens this continuity by ensuring patients have the medications they need as they transition into the skilled care setting, reducing the risk of early gaps in therapy. Together, these efforts contribute directly to better chronic disease control and align with quality measures that reward consistent patient engagement in their treatment plans.
Key Pharmacist Interventions and Synchrony’s Impact
Pharmacist-led transitions-of-care services center on a few core activities that, when performed consistently, create a seamless bridge from the hospital or skilled nursing facility to the next stage of recovery.
Synchrony ArrivalRX plays a pivotal role in supporting continuity of care during the critical handoff from the hospital to the skilled nursing facility. By coordinating with the discharging hospital, the program ensures a three-day supply of essential medications is sent with the patient upon arrival. This approach helps bridge the critical gap between hospital discharge and the skilled nursing facility’s first medication administration, reducing the risk of missed doses, therapy delays, and related complications. With medications in place from day one, care teams can focus on assessment and treatment rather than scrambling to resolve urgent access issues, ultimately supporting safer and more seamless transitions of care.
Medication reconciliation is the cornerstone of a safe transition from the hospital to a skilled nursing facility. Upon admission to the skilled nursing facility, Synchrony pharmacists review the complete list of medications the patient was taking and compare it with the prescriptions ordered at admission. This ensures that essential therapies are continued, unnecessary medications are discontinued, and any changes made during the hospital stay are intentional, clinically appropriate, and clearly documented. By addressing potential issues such as omissions, duplications, or dosing errors at the time of arrival, pharmacists provide the facility’s care team with an accurate, up-to-date medication plan that supports continuity of care from the beginning of their long term stay in a long-term care facility.
Synchrony Pharmacy’s Clinical Support Team also prevents delays in medication access. With an average prior authorization response rate of 86%, the team ensures patients receive necessary medications without interruption during their nursing home stay and beyond. In addition to managing prior authorizations, they perform formulary management and conduct high-cost medication reviews, helping to identify clinically appropriate and cost-effective alternatives when possible. Their streamlined processes reduce administrative burdens and help care teams stay focused on clinical priorities, ultimately promoting safer and more coordinated care as patients move from hospital to post-acute settings.
Interdisciplinary communication ensures that pharmacist insights reach the right decision-makers quickly, keeping the entire care team aligned on an accurate, up-to-date medication plan. This collaboration becomes even more impactful when paired with initiatives like Drive to Deprescribe, which targets the reduction of polypharmacy and the removal of inappropriate medications. At Synchrony Pharmacy, each resident’s regimen is reviewed in detail, with recommendations made to discontinue unnecessary therapies or adjust doses to better fit clinical needs. Our team in Indiana alone makes over 1,700 recommendations each month, with an average approval rate of 90 percent, underscoring the impact and trust placed in these interventions.
Post-discharge follow-up extends the safety net beyond the hospital or skilled nursing facility, ensuring patients remain supported as they transition home. Synchrony Rx@HOME connects with patients soon after discharge to confirm they have their medications, understand how to take them, and know how to access refills. This outreach also surfaces potential issues early, such as side effects, affordability concerns, or confusion about instructions, before they escalate into readmissions. Poor adherence can more than double the likelihood of returning to the hospital, and as many as 20% of readmissions are tied to preventable medication errors. Synchrony Rx@HOME emphasizes adherence from day one by ensuring patients leave with the right medications in hand, clear instructions, and a plan to stay on therapy. Together, these steps maintain continuity of care, improve outcomes, and support patient wellness beyond the point of discharge.
Value to Health Systems: Enhancing CMS Star Ratings
The Centers for Medicare & Medicaid Services (CMS) Star Ratings program evaluates the quality of Medicare Advantage and Part D plans, rewarding higher-performing plans with bonus payments, stronger reimbursement, and a competitive market edge. Among the many factors CMS considers, several directly align with the core work pharmacists perform during transitions of care.
Medication adherence is one measure closely monitored by CMS, particularly for chronic conditions such as hypertension, diabetes, and high cholesterol. Consistently taking medications as prescribed, at least 80 percent of the time, is considered clinically effective and can improve a plan’s Star Rating. Achieving this level of adherence begins the moment a patient arrives from the hospital. Ensuring they have the correct prescriptions, understanding how to take them, and have a clear plan to obtain refills helps maintain continuity of care and prevents gaps that could compromise recovery.
Reducing avoidable hospital readmissions also plays an important role. Readmission within 30 days often signals a gap in follow-up or care coordination, both of which are areas where pharmacists can intervene. By performing thorough discharge medication reconciliations and maintaining communication with providers, pharmacists help prevent medication-related problems that could send patients back to the hospital.
Another area where pharmacists have a measurable effect is in the avoidance of high-risk medications in older adults. Careful review of discharge medication lists allows them to identify potentially inappropriate drugs and suggest safer alternatives, improving patient safety and directly influencing CMS quality measures.
When these contributions are combined, they strengthen a plan’s overall performance across multiple Star Rating categories. The result is safer, more coordinated care for patients as they transition between settings.
Moving Forward: Expanding Pharmacist-Driven Care
Pharmacist involvement in transitions of care has a measurable impact on patient safety, readmission rates, and quality performance measures such as CMS Star Ratings. By ensuring accurate medication reconciliation, educating patients and caregivers, communicating effectively with the care team, and following up after discharge, pharmacists provide a critical safeguard during one of the most vulnerable points in a patient’s care journey.
Synchrony Pharmacy exemplifies how these principles can be put into practice across diverse care settings. Through its commitment to accuracy, collaboration, and patient-centered service, it supports safer medication use, improves adherence, and reduces the risk of avoidable hospital returns.
As healthcare continues to move toward value-based care, the role of pharmacists in transitions of care should not be optional, it should be an expected standard. Expanding these services across health systems is not only a matter of improving metrics, but also of ensuring patients have the support and resources they need to recover successfully and maintain their health long after they leave the facility.
References:
- Pollak TN, Renier CM, Curley JP, Haller IV. Pharmacist-led Transitions of Care: A Cohort Study on Admission Medication History Factors and Adjustments to the Discharge Medication List. Hospital Pharmacy. 2024;(3):239-244. doi:10.1177/001857872412981322.
- Miller D, Ramsey M, L’Hommedieu TR, Verbosky L. Pharmacist-led transitions-of-care program reduces 30-day readmission rates for Medicare patients in a large health system. American Journal of Health-System Pharmacy. 2020;(12):972-978. doi:10.1093/ajhp/zxaa071
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