Ambulatory Pharmacy as the Hub of Transitional Care

By Eunice Moore, PharmD, MS, PMP |

A Targeted Concierge Medication Program and Robust Data Analytics are Key to Care Continuity
The Affordable Care Act has mandated hospitals and health systems to lower readmission rates or face potentially harsh financial penalties. As a result, these organizations have begun to focus on better managing the transition of care among settings—primarily from hospital to home—to improve care continuity and mitigate some of the key factors that frequently land patients back in the hospital.
One of the most significant of these factors is medication adherence. According to researchers, after patients are discharged, up to 19 percent of them experience some sort of adverse event—nearly two thirds of which are medication-related.1 Patients frequently misuse their medications. Often, they simply don’t fill (or refill) their prescriptions as directed or, if they do, they don’t follow dosing instructions. And the ramifications can be considerable: at least one study estimates that hospital admissions related to medication issues cost the healthcare system an aggregate of $100 million each year.2


Delivering Meds to Beds

To address this, a growing number of health systems are turning to on-site ambulatory pharmacies to implement concierge medication (or “meds-to-beds”) programs. This enables them to proactively intervene with individuals most at risk for non-adherence and possible readmission by delivering discharge medications to their bedside and thoroughly counseling them on their treatment regimen before they leave the hospital. The goal, of course, is to increase compliance while ensuring that the hospital-to-home transition is smooth and successful — and doesn’t result in another admission.   
Just as each hospital and health system’s needs and goals are different, so is the approach to designing and implementing an effective concierge medication program. There is no one-size-fits-all, off-the-shelf solution. However, by working with an experienced consulting partner, an organization can streamline the complexities and costs often associated with devising an impactful program that meets its specific requirements.
It starts with empowering key stakeholders. Working with medical staff and representatives from marketing, finance, HR, quality and IT will set the stage for an effective pilot program. This cross-functional team can identify a trial unit or patient population and associated clinician champions—nurses, case managers, physicians and inpatient pharmacists—willing to work collaboratively to ensure the pilot’s initial success so it can expand quickly to other areas.
Organizing a collaborative, multi-disciplinary design team (for example: IT, marketing, education, clinician champions, and operations) and conducting weekly project management meetings will also help the implementation proceed smoothly. The consulting partner should also spearhead socializing the concierge program throughout the facility prior to launch to accelerate a fast start upon go-live. 
Above all, the most essential component of launching an effective concierge program is communication. It is crucial to include all stakeholders (clinicians, case management and discharge planning), from admissions to discharge, to understand three key factors for each patient:


  • The medications that will be prescribed at discharge
  • How the patient will pay for them
  • Whether lower-cost medications are available and should be prescribed

Analytics: The Next Level

While traditional concierge medication programs have proven to be effective, they are often passive and untargeted. Many organizations have bolstered their initiatives with data-driven analytics to further improve medication adherence and readmission rates. By unlocking the vast potential of patient data, this technology can laser focus a concierge medication program and optimize its impact in four key ways:
  1. Targeting patients: Identifying and prioritizing high-risk patients and high-value prescriptions.
  2. Managing workflow: Guiding processes and focusing on increasing patient engagement.
  3. Tracking patients post-discharge: Identifying patients who have yet to fill their prescriptions—whether at the ambulatory pharmacy or elsewhere—and alerting the pharmacy, hospital call center or physician for follow-up.
  4. Measuring economic and clinical impact: Tracking results in near-real time through online dashboards to enable program optimization and continuous improvement.
A quality data analytics solution should examine information from numerous sources, including pharmacy benefits managers, claims, electronic health records and pharmacy point of sale systems. It should look at both clinical indicators (comorbidities, encounter data, medication history, etc.) and socioeconomic factors (age, payer status, discharge location, etc.) to connect touch points throughout the care continuum and identify and fill care gaps that might occur across settings.
Pharmacists and other care team members can then utilize this output to pinpoint patients who pose the most risk for medication non-adherence and/or readmission and proactively intervene with them to ensure compliance and care continuity. Often, the resulting efficiency improvements and readmission penalty avoidance can cover the technology investment.
This is why a robust concierge medication program with effective data analytics simply makes sense in today’s value-driven healthcare environment. With reimbursement and payment structures predicated on improving care quality and keeping people healthy, the stakes are high for hospitals and health systems to ensure that discharged patients remain discharged patients. Identifying and intervening with those most at risk for a medication-related return hospital stay is an efficient and effective way of achieving that goal.
To learn more about how ambulatory pharmacy can drive medication adherence and care transitions to help health systems meet value-based care goals, click here.  


1. Foster, A.J., Murff, H.J., Peterson, J.F. et al. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital, Ann Intern Med, 2003 Feb 4; 138(3): 161-7.
2. 11 Osterberg, L., Blaschke, T. (2005). Adherence to medication. N Engl J Med, 353(5), 487-497.

About the Author

Eunice Moore, PharmD, MS, PMP

Managing Director
Pharmacy Healthcare Solutions
View Bio