Multisite implementation of a pharmacist-led telehealth transitions-of-care program: Design and execution

PURPOSE: To describe the design of a pharmacist-led telehealth transitions-of-care (TOC) program and its implementation across multiple hospitals within a large health system containing onsite health system-owned pharmacies. SUMMARY: The telehealth TOC program led by centralized pharmacists was implemented in 2 phases. Eligible patients included those with 3 or more discharge medication prescriptions filled at the onsite health system-owned pharmacy following a hospital or emergency department visit. During the pilot phase, the service was offered to patients 18 years of age or older discharged from a single hospital in the health system while the expansion phase included patients discharged from 5 additional hospitals and those of all ages. Additional services were also implemented during the expansion phase, including the incorporation of pharmacy services coordinators (PSCs) who assisted with patient outreach and prior authorizations, a bedside medication delivery service, and dedicated pharmacy personnel who brought medications to the bedside and offered enrollment into the TOC program at that time. Enrolled patients were contacted by a pharmacist within 2 to 3 business days after discharge for a TOC visit via telephone or video call at no cost. During the visit, the pharmacist provided education on discharge medications, performed a postdischarge medication reconciliation, and resolved any medication-related problems. Implementation of this service involved collaboration with organizational leadership and multidisciplinary colleagues throughout the health system. CONCLUSION: Successful implementation of the TOC program enabled continuity of care and optimized medication management following discharge, with the goal of improving patient outcomes.