Transition of Care and Medication Reconciliation

Author(s): Jeffrey Oken, MD, Raj Desai, MD

Originally published:04/18/2016

Last updated:04/18/2016


As national awareness of medical errors and quality deficiencies that occur within particular healthcare settings continues to rise, an expanding evidence base points to similar problems that occur during transitions of care between facilities4. The majority of healthcare expenditures goes towards managing patients with multiple comorbidities and their complex chronic conditions, these patients often require visits to multiple healthcare providers in a variety of settings and thus are most susceptible to fragmented transition of care. Transition of care is defined as a continuous process in which a patient’s care shifts from one hospital setting to another, such as from an acute hospital facility to an acute inpatient rehabilitation facility or from an acute inpatient rehabilitation facility to a skilled nursing facility. Poorly managed transitions of care not only increase healthcare costs and decrease quality of care but, most importantly, adversely affect patient safety. Approximately 20% of Medicare patients discharged from hospitals were rehospitalized within 30 days, and of that 34% were readmitted within 90 days13. The 2002 Institute of Medicine (IOM) report, Crossing the Quality Chasm, described the US system as decentralized, complicated, and poorly organized. It specifically noted “layers of processes and handoffs that patients and families find bewildering and clinicians view as wasteful.” Quantitative evidence increasingly indicates that patient safety is jeopardized during transition of care3.

A standardized approach to transition of care has been a key component of the Joint Commission patient safety goals. These transitions are vulnerable exchange points that can potentially drain healthcare services, unnecessarily. Changes in this area can improve quality of care and can both reduce costs and the number of sentinel events. Sentinel events, as defined by The Joint Commission, “are any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient, not related to the natural course of the patient’s illness”10. One aspect of transition of care that can dramatically reduce the number of sentinel events for a rehabilitation facility is medication reconciliation. Medication reconciliation is defined by the Joint Commission as “the process of obtaining a list of the patient’s prior to admission medication and comparing and consolidating with medications taken at the hospital with any newly ordered medications in order to resolve discrepancies or potential problems.”10 Failure to reconcile medications across transition of care is a key source of sentinel events that can ultimately lead to discharge back to the acute care facility1.


As the acuity of patients being admitted to inpatient rehabilitation facilities (IRF) increases, a detailed transition of care report amongst providers should be expected for patient safety and maintaining quality of care in addition to minimizing in healthcare costs. Traditionally, the transition of care between an acute care facility and IRF consists of a discharge summary, discharge medication reconciliation, medication administration report, and physician documentation. Often times these are sufficient for transition of care but there are instances when additional records would be crucial for continuity of quality care.

Lack of official relationships between facilities often leads to fragmented communication between caregivers and, consequently, difficulty with obtaining medical records. Obtaining prior imaging for comparison is often required to determine the acuity of a new finding. Often times, obtaining prior imaging is time intensive and the ease of sharing medical records severely limits the ability to adequately treat or reassure the patient, thus leading to unnecessary diagnostic imaging and patient burden. A murmur in a post-CABG patient, previously documented in the cardiologist’s notes that were not sent with the discharge paperwork, can potentially be an emergency to the admitting physiatrist. Again, limitations in accessing the cardiology documentation and differences in computer software make it difficult to transmit medical records between facilities in a timely manner – especially during emergent situations.

The burden on the admitting physiatrist substantially increases as more acute patients are being admitted to IRF to thoroughly reconcile each medication for each patient – leaving less time for the clinical evaluation. Medication reconciliation involves comparing the patient’s current list of medications against the physician’s admission, transfer, and/or discharge orders and identifying any discrepancies using clinical judgement and expertise1. This is one of the key components of facilitating a safe transition of care between facilities according to The Joint Commission. Often times, many sentinel events are caused by improper medication reconciliations. For example, information about a medication that a patient may have been prescribed at IRF may not be accurately communicated to the nursing home to which the patient was discharged and potentially omitting the medication. Forster et el. found that 19% of patients discharged from the hospital experienced an associated adverse event within 3 weeks; 66% of these were adverse drug events6. To help alleviate this burden, the Joint Commission has determined that the involvement of pharmacists is one of the activities with a positive effect on transitions of care1. Medication reconciliation should not be viewed as an accreditation function, rather as an important element of patient safety7.

Inpatient healthcare facilities can fairly be expected to provide a discharge summary with medication reconciliation detailing a patient’s inpatient stay, thus providing adequate background information, in case any acute medical issues arise and allowing for the continuity of care. Often times due to rushed discharges, these summaries are inadequate or missing. They may leave out the rationale for duration of antibiotics, anticoagulation recommendations or crucial postoperative follow up dates. This creates an additional obstacle for the admitting physiatrist and an additional vulnerable exchange point. As we reconcile the medications – we question how long to continue antibiotics and its necessity or whether or not to resume anticoagulation in a TBI patient due to patient’s high risk for thrombosis during rehabilitation. Aggarwal discovered that ‘more than 40% of medication errors and 20% of all adverse drug events have been attributed to poor communication and inadequate reconciliation in handoffs during admission, transfer and discharge of patients. Of these errors, about 20% are believed to result in harm. Many of these errors would be averted if medication reconciliation processes were in place1.”

Medication reconciliation is meant to be a methodical addendum of the medication history-taking process that has been used by physicians for years. Its recent emphasis by The Joint Commission was developed to ensure that medications were not added, overlooked, or changed inadvertently during transitions of care.  Inpatient rehabilitation facilities have access to licensed and trained pharmacists who can assist with medication reconciliation – often times allowing us to decide on duration of antibiotics after knowing the patient already had received 7 days of antibiotics at the acute care facility or that the patient was actively receiving anticoagulation up until discharge. Utilizing pharmacies at rehabilitation facilities can greatly reduce the number of sentinel events, increase patient satisfaction, reduce unnecessary costs and improve the quality of care for each patient.

As physiatrists, in many circumstances, we are the final healthcare provider many patients see prior to returning home. It now becomes our responsibility to coordinate the core functions of the discharging and accepting teams during transitions of care – beginning with accurate and detailed mediation reconciliation. Thus, in order for us to successfully orchestrate these functions, an ideal starting point would be to initiate collaboration with in-house pharmacists to better facilitate transfer of care and to include a detailed discharge summary outlining our inpatient rehabilitation events. These two facets of transition of care can greatly reduce the number of readmission rates, decrease unnecessary costs and improve the quality of care3.


The University of Colorado healthcare system is utilizing transition coaches. These coaches are distinctly different than home health nurses, who provide skilled care, and social workers, who address social issues. These coaches facilitate strategies and communication between the patients and their families to provide them with the tools and knowledge to address any transition of care related issues. This service has decreased readmission rates and saved over $365,000 per coach.


The gaps in knowledge are that despite expensive electronic health records which were supposed to make the process quicker for health care providers and safer for patients, the reality is that the process has become more burdensome for physicians and not much safer for patients. This may be due to the large amounts of medication that rehabilitation patients are on or the lack of an efficient process.


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  12. Kaushal, R., Bates, D. W., Poon, E. G., Jha, A. K., Blumenthal, D. & the Harvard Interfaculty Program for Health Systems Improvement NHIN Working Group (2005a). Functional gaps in attaining a national health information network. Health Affairs, 24, 1281-1289.
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  15. Naylor MD, Aiken LH, Kurtzman ET, et al. The care span: the importance of transitional care in achieving health reform. Health Aff (Millwood) 2011;30:746–54.

Author Disclosure

Jeffrey Oken, MD
Nothing to Disclose

Raj Desai, MD
Nothing to Disclose

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