February 27, 2025 • 13 mins
In this episode, Yara Al-Shaer and transitions of care pharmacist Laressa Bethishou discuss strategies for preventing medication errors during transitions of care, with an emphasis on medication reconciliation, and effective collaboration across healthcare teams.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:03):
That's the First Fill.
My name is Yaraand I serve as the executive fellow at Education
and I'll be the host for today.
Today, we're diving into a critical aspectof patient safety, transitions of care,
effective transition of care interventions,including medication
reconciliation and interdisciplinarycollaboration, play a vital role
in preventing medication errors, adversedrug events and hospital readmissions.
(00:27):
Pharmacies are at the forefront of ensuringcontinuity of care for verifying medication
histories, admissionto optimizing therapy at discharge.
Joining me today is LarissaBethishou, transition of care pharmacist
dedicated to improving medicationsafety and transition of care best practices.
In part one of the series, we highlighted the 2024
(00:49):
2025 ISMP Best Practice 21
and explored how pharmacists contributeto hospital performance metrics
by aligning with the CMS and JointCommission quality measures.
Today, in part two we’ll focus on strategiesfor preventing medication
errors during transitions of care,with an emphasis on medication
reconciliation and effective collaborationacross health care teams.
(01:11):
Welcome Larissa, and to start off,could you share a bit about your role
and responsibilitiesas a transitions of care pharmacist?
Absolutely. Thank you so much for having me.
I practice as a transitions of care pharmacistsin the inpatient setting in a community hospital
in Southern California,and I am faculty at a pharmacy school,
so my role involves both patient care as wellas incorporating students into my workflow.
(01:35):
I primarily see patients who are discharging
from the hospitaland who are at high risk for readmission.
And so high risk for readmission can meandifferent things at different institutions.
But for us it is patients
who have high risk medicationslike anticoagulants or antibiotics.
Those who are coremeasure patients like stroke, heart failure
(01:58):
and ACS.
And it also means, like patientswho are discharging to SNFs
and interventions will vary againdepending on the needs of the patient.
But at minimum, we are providingdischarge medication, reconciliation,
patient education, and then really incorporatingkind of assessing and addressing access
and adherence barriers where appropriateand handing off to the next of care
(02:22):
provider again,where that is needed or appropriate.
Thank you for sharing what you do.
Reflecting back on our discussion last week,one of the ISMP new best practice strategies
we spoke about focuses on medication
reconciliation to prevent medication errorsduring transitions of care.
Laressa, can you share some strategiesfor ensuring accuracy
and continuity of carewhen performing a medication reconciliation?
(02:46):
Yeah, absolutely.
Medication reconciliation is interesting
because it is very simple in concept,but it gets very complex in execution.
As anyone who has performeda medication reconciliation can tell.
And so I think that there's a few thingsthat can really help with doing this effectively.
First and foremost, in alignmentwith the pharmacist patient care process.
(03:08):
The first step is really to collectinformation from the patient.
And so it starts with collecting thatbest possible medication history.
And that really makes all the differencein setting
a very solid foundation for having the information
to effectively reconcile medicationsonce the patient leaves that encounter.
So a best possible medication history involves
(03:32):
verifying information against a secondary source,
like a list from a physicianor a pharmacy fill history.
But it really relies on interviewing the patientand using open ended questions
to prompt the patient to really understandall of the medications that are taking,
including some of the things they might not thinkto tell you they're taking like over-the-counter
(03:54):
medications or medications that are as needed.
And so they're not taking them daily,but they're still on their medication
less than affecting their care.
And it also means that in interviewingthe patient,
you're trying to tease out some of those accessand adherence barriers.
(04:14):
And so it's really importantwhen you identify that a patient
is not taking something correctlyto try to understand what prompted that
adherence challenge.
Was it because the patient could not affordthe medication?
Was it because someone actually told themto stop taking it?
Was it because they had a friend
(04:35):
who told themthat the medication was not good for them?
So really kind of understanding that fullyand really understanding
what the patient takes and why they take itthe way they do and it helps inform
how we can best support themso that when they are discharging
from that encounter,whether it's outpatient or an inpatient discharge,
(04:56):
we're making sure that they are actually gettingall the medications that they need, as
well as the education and the supportso that they can actually use their medications
optimally and get the full benefit from them.
Thanks for those valuable insights, Laressa.
Now let's shift gears to collaborationwith health care providers, an essential aspect
transition of care.
How can pharmacists effectively workwith physicians, nurses, case managers
(05:20):
and other health care professionalsto improve patient outcomes?
So effective transitions of carereally ideally should always be interprofessional,
the idea being thatthe patient is at the center of it
and each profession brings their expertiseto support the patient collaboratively.
And that practice model is where
(05:42):
I have seen the most effectivetransitions of care interventions.
So at one institution that I worked with,
we targeted all of our heart failure patientsand we had a very
clearly defined goals and standardized workflow.
And so we knew that any timea heart failure patient was admitted,
pharmacy would be involved at these checkpoints.
(06:03):
And there was clear understanding between the teamthat this was the value that pharmacy brought.
So, for example,when a discharge order was placed,
nursing would contact usand they would wait for us and they would
kind of make spaceto provide those two interventions.
But on the other side of that,
because it was a collaborative approachwith clearly defined roles,
(06:25):
it also meant that as a pharmacistI had resources.
And so if I knew that a patient needed supportfrom case management
or from a nutritionistor from physical or occupational therapy,
there was already a process in placeby which I could connect with them.
So that's ideal.
If you can have this collaborative approachwith the team where you've kind of pre-set
(06:46):
that criteria, you know exactlywhat each person will do and when.
I've also been at institutions where thatthat process has not been as well defined.
And in those instancesit has been helpful to build those relationships
kind of one at a time and as needed.
So, for example,I see a lot of patients discharging
with complex insulin regimensfor diabetes management.
(07:10):
And so I started a few years agoat my current institution
connecting with our diabetes educators,and I would loop them in when I had a discharge
and ask if they would work with meto provide discharge education.
And so it helped thembecome more familiar with pharmacy as well.
And they became an excellent resource for me.
But over time they started then doing the sameand looping me in and asking for help
(07:31):
when they had complex insulin regimensand wanted a pharmacist to look at them.
Because I think it's really helpingother professions understand
the shared goal, but also how we can mutually worktogether to best support the patient.
I agree interprofessional collaborationis important, especially in a team.
So thank you, Laressa, that’s great advice.
(07:53):
And what are some of the biggest challengesin optimizing transition of care
and how can pharmacies play a rolein overcoming these challenges?
I think the absolute biggest challengeis that there are not
universal standardized processesfor effective transitions of care.
There is certainly a greater awarenessof how important
it is to effectively transition patientsthrough the health care system.
(08:15):
And with that, as you mentioned, ISMP
had best practices around it, JointCommission, CMS.
This is all very helpful and it
shinesa spotlight on transitions of care interventions.
But again, each institution does it differently.
And so it's very differentwhen to provide that continuity of care.
(08:36):
So I think that is the biggest challenge.
What I think pharmacists can do to help addressit is regardless
of whether you are a pharmacistin a dedicated transitions of care role
or you are working with patientsand really any capacity and setting
viewing patient carethrough that lens of transitions of care.
(08:58):
Every patient is coming from somewhere.
They're going somewhere else.
They're moving between multiple settings,multiple providers.
And so looking at their care through that lens of
how can I comprehensively evaluatetheir medications, how can I make sure
that we're not just focusing inon the primary issue,
but neglecting how changes in their healthstatus and changes in their lives
(09:21):
and their medications will affectall of their other therapies and treatments.
And so I think that makes a big differencebecause then we are
supporting our patientsand making sure that they are
getting
the kind of optimal medication regimen they need.
And I think the other piece of thatis to handoff to the next of care provider
(09:42):
when possible.
That, I think is a challenge in and of itself.
We don't always have processes to do that.
I know with a few years agothe Transitions of Care Committee
made a handoff communication tooland so different institutions
again will have different processes by whichthey can handoff to the next care provider.
(10:02):
But I think that at minimum, having that awarenessto approach patient care in that way
and then handing off
when there is critical informationthat the next of care provider needs to know makes
a really big difference in supporting patientsthrough the continuum of care.
Thank you. That was great.
Finally, for pharmacists who are interestedin getting more involved in transitions
(10:24):
or shifting into a transition of carefocused role, what advice would you give them?
For those who are able to pursueone residency is excellent
as a way to gain valuable experienceand develop skills
that will support pharmacists in
moving into a dedicated TOC role.
(10:45):
There are PGY2
residencies, but that is not necessarily required
for those who are not able to do a PGY1or that's not the path that they took.
I think focusing in on the individual skills
and developing themwithin their respective practice settings
can still really lend itself
to becoming an effective transitionsof care pharmacists.
(11:09):
And to my earlier point, again,every pharmacist encounters
transitions of carewhether or not they are in a dedicated role.
And so focusing on developing
medication, reconciliation skills,
interview skills, being able to collectthat best possible medication history,
being able to provide a comprehensive medicationeducation that includes
(11:31):
lifestyle modifications and preventative care,
and even being able to assess and address
those access and adherence barriers
can support pharmacistsmoving into a transitions of care role
because they have essentially developed skills
that will really support themin providing effective patient care.
Laressa,thank you for sharing your expertise today.
(11:54):
This has been highly informative discussionon how pharmacists
can enhance medication safety,collaboration and transitions of care.
All right, let's summarizemajor takeaways from our time here today.
One, interprofessional care is crucialin transitions of care because it allows
for coordinated, comprehensive patient managementimproving overall patient outcomes.
One of the first and most important stepin medication reconciliation is collecting
(12:16):
a informative and complete medicationhistories, admission.
And finally, pharmacies play a key rolein coordinating with other health care
professionals, ensuring seamless care transitionsand reducing medication related issues.
All right, folks,that's all the time we have for today.
If you haven't listened to partone of this month's first full podcast yet,
(12:37):
it was released last week.
In that episode we highlighted the 2024-2025
ISMP Best Practice 21
and explored key CMS and JointCommission quality measures.
Be sure to check it out.
For those interested in transitions of care.
We've just launched the BCGP webinarseries, and APhA’s
Case Study Recertification series for 2025.
(13:00):
This month we're focusing on addressing socialdeterminants of health in transition of care.
So don't miss it.
So and finally,don't forget to visit the Learning Library
to earn CE credit for this month podcast.
We'd love to hear your feedback on the new format.
Take care and thanks for listening.
That's the First Fill.
My name is Yaraand I serve as the executive fellow at Education
and I'll be the host for today.
Today, we're diving into a critical aspectof patient safety, transitions of care,
effective transition of care interventions,including medication
reconciliation and interdisciplinarycollaboration, play a vital role
in preventing medication errors, adversedrug events and hospital readmissions.
(00:27):
Pharmacies are at the forefront of ensuringcontinuity of care for verifying medication
histories, admissionto optimizing therapy at discharge.
Joining me today is LarissaBethishou, transition of care pharmacist
dedicated to improving medicationsafety and transition of care best practices.
In part one of the series, we highlighted the 2024
(00:49):
2025 ISMP Best Practice 21
and explored how pharmacists contributeto hospital performance metrics
by aligning with the CMS and JointCommission quality measures.
Today, in part two we’ll focus on strategiesfor preventing medication
errors during transitions of care,with an emphasis on medication
reconciliation and effective collaborationacross health care teams.
(01:11):
Welcome Larissa, and to start off,could you share a bit about your role
and responsibilitiesas a transitions of care pharmacist?
Absolutely. Thank you so much for having me.
I practice as a transitions of care pharmacistsin the inpatient setting in a community hospital
in Southern California,and I am faculty at a pharmacy school,
so my role involves both patient care as wellas incorporating students into my workflow.
(01:35):
I primarily see patients who are discharging
from the hospitaland who are at high risk for readmission.
And so high risk for readmission can meandifferent things at different institutions.
But for us it is patients
who have high risk medicationslike anticoagulants or antibiotics.
Those who are coremeasure patients like stroke, heart failure
(01:58):
and ACS.
And it also means, like patientswho are discharging to SNFs
and interventions will vary againdepending on the needs of the patient.
But at minimum, we are providingdischarge medication, reconciliation,
patient education, and then really incorporatingkind of assessing and addressing access
and adherence barriers where appropriateand handing off to the next of care
(02:22):
provider again,where that is needed or appropriate.
Thank you for sharing what you do.
Reflecting back on our discussion last week,one of the ISMP new best practice strategies
we spoke about focuses on medication
reconciliation to prevent medication errorsduring transitions of care.
Laressa, can you share some strategiesfor ensuring accuracy
and continuity of carewhen performing a medication reconciliation?
(02:46):
Yeah, absolutely.
Medication reconciliation is interesting
because it is very simple in concept,but it gets very complex in execution.
As anyone who has performeda medication reconciliation can tell.
And so I think that there's a few thingsthat can really help with doing this effectively.
First and foremost, in alignmentwith the pharmacist patient care process.
(03:08):
The first step is really to collectinformation from the patient.
And so it starts with collecting thatbest possible medication history.
And that really makes all the differencein setting
a very solid foundation for having the information
to effectively reconcile medicationsonce the patient leaves that encounter.
So a best possible medication history involves
(03:32):
verifying information against a secondary source,
like a list from a physicianor a pharmacy fill history.
But it really relies on interviewing the patientand using open ended questions
to prompt the patient to really understandall of the medications that are taking,
including some of the things they might not thinkto tell you they're taking like over-the-counter
(03:54):
medications or medications that are as needed.
And so they're not taking them daily,but they're still on their medication
less than affecting their care.
And it also means that in interviewingthe patient,
you're trying to tease out some of those accessand adherence barriers.
(04:14):
And so it's really importantwhen you identify that a patient
is not taking something correctlyto try to understand what prompted that
adherence challenge.
Was it because the patient could not affordthe medication?
Was it because someone actually told themto stop taking it?
Was it because they had a friend
(04:35):
who told themthat the medication was not good for them?
So really kind of understanding that fullyand really understanding
what the patient takes and why they take itthe way they do and it helps inform
how we can best support themso that when they are discharging
from that encounter,whether it's outpatient or an inpatient discharge,
(04:56):
we're making sure that they are actually gettingall the medications that they need, as
well as the education and the supportso that they can actually use their medications
optimally and get the full benefit from them.
Thanks for those valuable insights, Laressa.
Now let's shift gears to collaborationwith health care providers, an essential aspect
transition of care.
How can pharmacists effectively workwith physicians, nurses, case managers
(05:20):
and other health care professionalsto improve patient outcomes?
So effective transitions of carereally ideally should always be interprofessional,
the idea being thatthe patient is at the center of it
and each profession brings their expertiseto support the patient collaboratively.
And that practice model is where
(05:42):
I have seen the most effectivetransitions of care interventions.
So at one institution that I worked with,
we targeted all of our heart failure patientsand we had a very
clearly defined goals and standardized workflow.
And so we knew that any timea heart failure patient was admitted,
pharmacy would be involved at these checkpoints.
(06:03):
And there was clear understanding between the teamthat this was the value that pharmacy brought.
So, for example,when a discharge order was placed,
nursing would contact usand they would wait for us and they would
kind of make spaceto provide those two interventions.
But on the other side of that,
because it was a collaborative approachwith clearly defined roles,
(06:25):
it also meant that as a pharmacistI had resources.
And so if I knew that a patient needed supportfrom case management
or from a nutritionistor from physical or occupational therapy,
there was already a process in placeby which I could connect with them.
So that's ideal.
If you can have this collaborative approachwith the team where you've kind of pre-set
(06:46):
that criteria, you know exactlywhat each person will do and when.
I've also been at institutions where thatthat process has not been as well defined.
And in those instancesit has been helpful to build those relationships
kind of one at a time and as needed.
So, for example,I see a lot of patients discharging
with complex insulin regimensfor diabetes management.
(07:10):
And so I started a few years agoat my current institution
connecting with our diabetes educators,and I would loop them in when I had a discharge
and ask if they would work with meto provide discharge education.
And so it helped thembecome more familiar with pharmacy as well.
And they became an excellent resource for me.
But over time they started then doing the sameand looping me in and asking for help
(07:31):
when they had complex insulin regimensand wanted a pharmacist to look at them.
Because I think it's really helpingother professions understand
the shared goal, but also how we can mutually worktogether to best support the patient.
I agree interprofessional collaborationis important, especially in a team.
So thank you, Laressa, that’s great advice.
(07:53):
And what are some of the biggest challengesin optimizing transition of care
and how can pharmacies play a rolein overcoming these challenges?
I think the absolute biggest challengeis that there are not
universal standardized processesfor effective transitions of care.
There is certainly a greater awarenessof how important
it is to effectively transition patientsthrough the health care system.
(08:15):
And with that, as you mentioned, ISMP
had best practices around it, JointCommission, CMS.
This is all very helpful and it
shinesa spotlight on transitions of care interventions.
But again, each institution does it differently.
And so it's very differentwhen to provide that continuity of care.
(08:36):
So I think that is the biggest challenge.
What I think pharmacists can do to help addressit is regardless
of whether you are a pharmacistin a dedicated transitions of care role
or you are working with patientsand really any capacity and setting
viewing patient carethrough that lens of transitions of care.
(08:58):
Every patient is coming from somewhere.
They're going somewhere else.
They're moving between multiple settings,multiple providers.
And so looking at their care through that lens of
how can I comprehensively evaluatetheir medications, how can I make sure
that we're not just focusing inon the primary issue,
but neglecting how changes in their healthstatus and changes in their lives
(09:21):
and their medications will affectall of their other therapies and treatments.
And so I think that makes a big differencebecause then we are
supporting our patientsand making sure that they are
getting
the kind of optimal medication regimen they need.
And I think the other piece of thatis to handoff to the next of care provider
(09:42):
when possible.
That, I think is a challenge in and of itself.
We don't always have processes to do that.
I know with a few years agothe Transitions of Care Committee
made a handoff communication tooland so different institutions
again will have different processes by whichthey can handoff to the next care provider.
(10:02):
But I think that at minimum, having that awarenessto approach patient care in that way
and then handing off
when there is critical informationthat the next of care provider needs to know makes
a really big difference in supporting patientsthrough the continuum of care.
Thank you. That was great.
Finally, for pharmacists who are interestedin getting more involved in transitions
(10:24):
or shifting into a transition of carefocused role, what advice would you give them?
For those who are able to pursueone residency is excellent
as a way to gain valuable experienceand develop skills
that will support pharmacists in
moving into a dedicated TOC role.
(10:45):
There are PGY2
residencies, but that is not necessarily required
for those who are not able to do a PGY1or that's not the path that they took.
I think focusing in on the individual skills
and developing themwithin their respective practice settings
can still really lend itself
to becoming an effective transitionsof care pharmacists.
(11:09):
And to my earlier point, again,every pharmacist encounters
transitions of carewhether or not they are in a dedicated role.
And so focusing on developing
medication, reconciliation skills,
interview skills, being able to collectthat best possible medication history,
being able to provide a comprehensive medicationeducation that includes
(11:31):
lifestyle modifications and preventative care,
and even being able to assess and address
those access and adherence barriers
can support pharmacistsmoving into a transitions of care role
because they have essentially developed skills
that will really support themin providing effective patient care.
Laressa,thank you for sharing your expertise today.
(11:54):
This has been highly informative discussionon how pharmacists
can enhance medication safety,collaboration and transitions of care.
All right, let's summarizemajor takeaways from our time here today.
One, interprofessional care is crucialin transitions of care because it allows
for coordinated, comprehensive patient managementimproving overall patient outcomes.
One of the first and most important stepin medication reconciliation is collecting
(12:16):
a informative and complete medicationhistories, admission.
And finally, pharmacies play a key rolein coordinating with other health care
professionals, ensuring seamless care transitionsand reducing medication related issues.
All right, folks,that's all the time we have for today.
If you haven't listened to partone of this month's first full podcast yet,
(12:37):
it was released last week.
In that episode we highlighted the 2024-2025
ISMP Best Practice 21
and explored key CMS and JointCommission quality measures.
Be sure to check it out.
For those interested in transitions of care.
We've just launched the BCGP webinarseries, and APhA’s
Case Study Recertification series for 2025.
(13:00):
This month we're focusing on addressing socialdeterminants of health in transition of care.
So don't miss it.
So and finally,don't forget to visit the Learning Library
to earn CE credit for this month podcast.
We'd love to hear your feedback on the new format.
Take care and thanks for listening.
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