PSW Transitions of Care Toolkit

This toolkit was developed by the Practice Advancement Leadership Team (PALT), formerly 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 Goal: Advancing 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 Contents

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.

PPMI - Transitions of Care Project Video

Discharge Medication Reconcilliation

The process of comparing a patient's medication orders at discharge to the medications on the patient’s profile prior to admission.

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Discharge Patient Education

Medication counseling services provided to the patient prior to discharge.

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Discharge Prescription Management

Discharge prescription management services are defined as bedside delivery and discharge prescription filling.

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Pharmacy Hand-off Communication

A formal process for communicating medication changes made in the inpatient setting to pharmacists in the outpatient setting.

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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.

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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