A practical guide for pharmacists to establish a transitions of care program in an outpatient setting

To improve understanding of the logistics of transitions of care (TOC) clinics and to provide guidance to pharmacists in developing and implementing a new TOC clinic or improving an existing one.

Outpatient TOC clinic within an ambulatory care practice.

Two general internal medicine practices collaborated with a university health system to create an interdisciplinary TOC clinic to improve quality and continuity of patient care. The clinic accommodates any patients of the practice who are not able to get an appointment with their primary care physician within 1 to 2 weeks of discharge from any hospital. Physician residents, an attending physician, a clinical pharmacist, a nurse, medical assistants, and a social worker (if necessary) are involved in the patient's care during the transition process.

Pharmacists can play a vital role in developing and implementing a TOC clinic or enhancing a current one. There are many logistical components to consider in developing a clinic, and this article provides guidance in the various steps required in creating a clinic, including support and coordination, personnel, workflow, operations, reimbursement, marketing, metrics, and measures.

This tool may help pharmacists implement or enhance an outpatient TOC clinic to improve patient care, quality, and continuity.