1. Henriksen, Brian PhD
  2. Stuckey, Nathan PharmD


Purpose: To diminish the negative effects associated with current care transitions (medication discrepancies, poor outcomes, adverse clinical events) while also giving pharmacists and other nonphysician practitioners opportunity to display their value to the health care system.


Methods: A retrospective medical record review was conducted on patients admitted to the hospital to observe whether a transitions of care management (TCM) services altered hospital readmission within 30 days. Sampling occurred via a convenience sample to capture all patients during the specified time frame.


Results: There were 226 hospital admissions during the study period (April 2015-February 2016). TCM encounters were performed for 75 of them. The number of readmissions with patients who had a Transitional Care Management encounter was only 5 of 24 total readmissions while 19 of the 151 patients who had not had a Transitional Care Management encounter were readmitted (6.7% compared with 12%; P = .174). These results demonstrate a 51% relative risk reduction.


Conclusion: The utilization of a Transitional Care Management team reduced the rate of readmission among Medicare beneficiaries by 50%. Economically, the TCM approach saves the hospital money by reducing the rate of readmissions that the hospital must reimburse.