Jefferson University Hospitals

Transitions of Care Program

The Transitions of Care Programs, also known as Care Coordination, began in November 2010 with the Heart Failure Program. Pneumonia and CABG have been added since then and progress is being made with ACS.These programs were developed to reduce the 30-day hospital readmission rates of patients.

The Heart Failure program is multidisciplinary with responsibilities crossing over disciplines. Pharmacists, nursing, case management and chart reviewers all evaluate patients for enrollment in the program. The program involves patient education regarding heart failure provided by nurses and pharmacists, nutritional education by a a registered dietician, and drug therapy education provided by pharmacists. Follow-up phone calls are made to each patient on days 2, 7, 14, 21, and 30 post-discharge. The phone calls are completed by the pharmacists. Each day one pharmacist is assigned to cover the program with assistance from pharmacy students or interns for phone calls.

The pharmacists' role in the pneumonia and CABG Care Coordination primarily involve provision of medication education prior to discharge. The pharmacists' role in the ACS program is yet to be determined.