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PSW Transitions of Care Toolkit

This toolkit was developed by the PSW Pharmacy Practice Model Initiative Leadership Team as a part of their Transitions in Care Initiative. To learn more about PPMI, a program lead by the American Society of Health-System Pharmacists, click here. To access the ASHP Transitions of Care Resource Center, click here.

Project GoalAdvancing pharmacy practice in transitions of care with the singular purpose of improving the lives of our patients.

Phase 1 Goal: Develop the resources to enable institutions to improve transitions of care and assist five institutions in advancing pharmacy practice regarding discharge, follow-up, and hand off.

Transitions of Care Toolkit

This toolkit was developed to provide resources to enable institutions to improve transitions of care in the following five domains: medication reconciliation, discharge medication management, discharge patient education, hand off, and follow-up. Each section of the toolkit is structured in the following manner:

  • Corresponding PPMI Recommendations

  • Wisconsin Transitions of Care Survey Results (full survey results available here)

  • Guidelines and Best Practices

  • Case Examples with Practice Resources

The following pages are provided as a PSW member service and can be accessed by members who are logged in to the website.

Discharge Medication Reconciliation
The process of comparing a patient's medication orders at discharge to the medications on the patient’s profile prior to admission.
Discharge Patient Education
Medication counseling services provided to the patient prior to discharge.
Discharge Prescription Management
Discharge prescription management services are defined as bedside delivery and discharge prescription filling.
Pharmacy Hand off Communication
A formal process for communicating medication changes made in the inpatient setting to pharmacists in the outpatient setting.
Follow-up Communication
Follow-up services offer patients direct access to their health care team after discharge or other care transition. These services are generally provided via appointment or telecommunications.

Implementation Site Case Studies

The following Wisconsin institutions are currently serving as pilot sites utilizing the toolkit content to implement various pharmacy driven transitions of care services. Keep watching this page for updates on their progress!

Pilot Site      Transition of Care Focus
Monroe Clinic Hospital, Monroe      Hand off
Follow-up

Mayo Clinic Franciscan Healthcare, La Crosse      Hand off

Aurora BayCare Medical Center, Green Bay      Discharge medication reconciliation

Westfields Hospital, New Richmond      Discharge medication reconciliation
Discharge patient education

St. Vincent Hospital, Green Bay      Discharge medication reconciliation
Discharge patient education


 

 



Implementation Site: Mayo Clinic Franciscan Healthcare, La Crosse, WI

Toolkit Table of Contents

The following resource pages are provided as a PSW member service. Members will have access to the materials by logging in.
PSW Transitions of Care ToolkitPSW Transitions of Care Toolkit

PSW Transitions of Care Toolkit

Business Case ResourcesBusiness Case Resources

Business Case Resources

Discharge Medication ReconciliationDischarge Medication Reconciliation

Discharge Medication Reconciliation

Discharge Patient EducationDischarge Patient Education

Discharge Patient Education

Discharge Prescription ManagementDischarge Prescription Management

Discharge Prescription Management

Follow-up CommunicationFollow-up Communication

Follow-up Communication

Pharmacy Hand off CommunicationPharmacy Hand off Communication

Pharmacy Hand off Communication

ReferencesReferences

References


PPMI - Transitions of Care Project Video


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