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Our program is designed to help facilitate the transitions of care (TOC) of select patients discharged from Henry Ford Hospital (HFH) with the aim of preventing 30-day readmissions, as well as improving cost avoidance measures. TOC, as defined by the Centers of Medicare and Medicaid, is a complex process requiring several actions and multiple disciplines to work together to ensure effective communication and coordination of care. Transitioning from the hospital setting to home, specifically, exposes vulnerability within our health systems, and errors have a high chance of occurring. Medication management and follow-up care are included in “the seven essential elements” needed for successful TOC. According to Burke and colleagues, an ideal framework for establishing successful transitions of care includes 10 domains, amongst which are: medication safety, educating patients to promote self-management, enlisting help of social and community supports, coordinating care among team members and monitoring and managing symptoms after discharge and outpatient follow-up, all of which are embedded into our program.

Publication Date


Project #4: The Effects of a Pharmacist-Led Transitions of Care Program after Hospital Discharge



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