Implementation and assessment of a required transitions-of-care residency rotation

The implementation of a required residency rotation in transitions of care (TOCs) and the resulting resident-led clinical interventions and learning experiences are described.

A newly required four-week TOC rotation was implemented for postgraduate year 1 (PGY1) pharmacy residents at Massachusetts General Hospital (MGH). Unlike acute care rotations, this learning experience encouraged residents to focus on providing direct patient care in a holistic manner and use pharmacologic and nonpharmacologic strategies to improve patient outcomes. The residents encountered patients with multiple comorbidities and were expected to manage common chronic diseases in a predominantly geriatric population. This rotation focuses on medically complex patients at high risk for readmission. TOC pharmacists and residents collaborate with multidisciplinary teams in both the outpatient and inpatient settings around the time of discharge from the hospital. All residents found the experience valuable and believed that the lessons learned would be incorporated into their future clinical practice. Residents gained a thorough understanding of conducting comprehensive medication reviews, assessing barriers to patients' understanding of and adherence to their medications, and working as part of a multidisciplinary team to address and overcome medication-related barriers during TOCs.

The TOC rotation at MGH provided PGY1 residents with a better understanding of the challenges of continuity of care, the impact of medication access on patient outcomes, and the promotion of medication adherence through patient engagement. The activities reported most valuable by residents included providing direct patient education, performing case reviews with the preceptor, collaborating with the preceptor on patient visits, and completing comprehensive medication reviews.