Evolution of Interdisciplinary Transition of Care Services in a Primary Care Organization

Transitions of care create complex management challenges for providers and leave patients vulnerable to medication errors and hospital readmissions. This article examines the evolution of an interdisciplinary team of pharmacists and nurse care managers and their impact on safe and effective transitions from the acute care settings back into primary care. This article explores successes and challenges of this primary-care-based clinic in managing patients safely through often-complex situations, and explores future directions for improving care processes and outcomes.