Patient Tools and Counseling for Improving Medication Management During Transitions in Care

Rhode Island Care Transitions Program


This medication management program is comprised of two main elements. The first element is the delivery of a focused comprehensive medication review and education service provided by a pharmacist following hospital discharge. The pharmacist visits the patient at home or other location (e.g., senior center) to perform a medication therapy review, demonstrate the ePHR, and assist patients in setting up the ePHR if they were agreeable towards using the system. The second element of the innovation is the use of the ePHR to support patients' role in being actively engaged in managing their medication and health information, and to facilitate information sharing across care settings and providers.

The intervention was implemented by a collaborative comprised of researchers from the University of Rhode Island College of Pharmacy, working in concert with the state's Medicare Quality Improvement Organization (QIO) and Division of Elderly Affairs, and local hospitals. ER-Card®, LLC provided the technology component. Patients were recruited for participation via the QIO's concurrent care transitions initiatives, by referrals from the state's Medicaid program, and by offering the program to hospitalized patients at a local community hospital.


Rhode Island Division of Elderly Affairs, local hospitals, University of Rhode Island College of Pharmacy, ER-Card®, LLC, and Healthcentric Advisors (formerly Quality Partners of RI)


Problem Addressed: Medication-related problems among community-dwelling patients are an important cause of morbidity, having consequences that cost the U.S. an estimated $177 billion yearly.(1) Significant opportunity exists for improving the quality of pharmacologic care across domains including education and documentation, monitoring, and promoting the use of and adherence to clinically important therapies.(2) Transitions in care introduce an additional dynamic which can further increase the risk of medication-related problems. Coleman et al found that approximately 14% of patients experienced a post-hospital medication discrepancy, with an approximately equal percentage of discrepancies arising from patient-associated and system-associated factors.(3) A research agenda for personal health records has been defined, which notes that patients having chronic conditions are a high priority for research investigating the utility of personal health records, given the "extremely high associated costs and the potential to improve quality and efficiency" among these patients.(4) To date, studies regarding the role of the community pharmacist in care transitions and promoting the use of ePHR systems are lacking.

Patient Population: This program targets recently hospitalized patients having diabetes, respiratory illness, and cardiovascular disease or related conditions (e.g. atrial fibrillation), prioritizing for elderly patients but including adults 50 years of age or older to augment the level of patient participation. Geographic location is limited to the state of Rhode Island.

Description of the Program: 

The program includes recruitment, arranging the home visit, conducting the medication regimen review, demonstrating the ePHR system, supporting patients in setting up their electronic record towards using the system for self-management and for sharing health information with care providers. Patient recruitment occurs via three main pathways. A first pathway is referral of patients from health coaches from Healthcentric Advisors, the state's Medicare-contracted quality improvement organization (QIO) that is delivering a care transitions intervention in association with the state's Aging and Disability Resource Center. A second pathway is referral from nurse case managers working within the state's Medicaid program. The third patient recruitment pathway occurs via on-site solicitation at a local community hospital. Promotional materials include a telephone number and email address providing a means for contacting project staff. After patients are screened for eligibility, the home visit is scheduled by the program pharmacist. The pharmacist home visit entails both a medication regimen review and demonstration of the ePHR program. Visits typically lasted between 90 - 120 minutes. If medication-related problems are identified during the medication regimen review, the pharmacist discusses the concern with the patient and if necessary encourages the patient to contact the prescriber and/or pharmacy. The pharmacist demonstrates the ePHR program using a laptop computer, and encourages the patient to utilize the system, noting that it may help improve the quality of care, and is offered at no cost. If the patient is agreeable to trying the ePHR system, the pharmacist supports the patient in inputting their information into the system, and further explains how the ePHR can be used to enhance self-management and health-information sharing.


Overall, patients found the pharmacist home visits and medication review session to be helpful; some patients adopted the ePHR technology, finding it to be useful in sharing information with their care providers. The medication profile reviews identified medication-related problems and/or discrepancies in 19 of the 30 patients completing a home visit, with some patients experiencing multiple medication-related problems. As categorized using the medication discrepancy tool, patient-level causes /contributing factors were identified in 6 of the 30 patients, while discrepancies identified as system-level were identified in 10 of the 30 patients. Nineteen patients completed a telephone survey: 3 of these patients (15.8%) were re-hospitalized within 30 days of their discharge. For comparison, 30 day readmission rates among patients participating in the state's broader ADRC CTI® initiative were 11.8% for coached patients and 23.5% for those that were lost to follow up and did not complete the intervention (data from 2011). Highlights of key findings include:

  • More than 300 hospitalized or recently-discharged patients were offered the intervention, 68 agreed to participate in the intervention, and 30 completed a pharmacist home visit. Two-thirds of patients (n = 20) agreed to utilize the electronic PHR system. These findings highlight the challenges in gaining the adoption of electronic personal health records among recently discharged patients.
  • Medication-related problems were frequently identified by the pharmacist, with 19 patients having a medication-related problem that was addressed by the pharmacist.
  • Of the 20 patients agreeing to utilize the ePHR system, 7 reported that they used the PHR to share information with care providers during post-discharge encounters.
  • Approximately 16% of patients of patients were re-hospitalized within 30 days, however data regarding rehospitalization rates were unavailable for 11 patients.


Context of the Program:The program was primarily coordinated by pharmacists/researchers from the University of Rhode Island College of Pharmacy and administrators and staff from ER-Card, LLC of West Warwick, RI, who supplied the ePHR technology and associated support services. Guidance was provided by Healthcentric Advisors, the state's Medicare-contracted quality improvement organization. This program was a supplementary component of an overarching grant to implement the CTI® model via the ADRC in the state. Funding to support the ER-Card® program component was provided by the state of Rhode Island legislature as a community service grant.

Planning and Development Process:

Securing the necessary agreements to permit patient recruitment for this initiative was a formidable endeavor. During the first quarter of program activity, program collaborators met frequently to address barriers to program implementation, which included the lack of process and permission for receiving ADRC referrals directly, and organizational differences between QIO and University stipulations for IRB approval. Alternative strategies for patient recruitment were pursued, which included partnership with the state's Medicaid program, and securing agreement for on-site recruitment at Kent Hospital in Warwick, RI. Presentations were made to nurses/nurse case managers from Medicaid and Kent Hospital to highlight the program and to request support for patient recruitment. Healthcentric advisors provided pharmacists with training on the CTI model and the role of health coaching when performing the home visits. Periodic meetings and conference calls addressed program issues such as challenges in patient recruitment, and strategies for getting patients to "yes". In 2012, meetings were held with several stakeholders including state Medicaid administrators and the RI legislature to advocate for the program's expansion.

Resources Used and Skills Needed:

The costs of the program can be categorized as clinical, administrative, and technological. Clinical costs were those associated with the pharmacist home visit service. We employed a clinical pharmacist at a rate of $50 / hour for approximately 2 days per week. In addition to completing the home visits, this pharmacist coordinated data collection, and facilitated information input into the ER-Card system. The pharmacist also worked to recruit patients at the collaborating hospital 1-2 days per week, and was responsible for scheduling patient home visits and responding to patient questions pertaining to medications and the ePHR system. The pharmacist found it to be challenging to coordinate the patient scheduling and perform the home visits with part-time dedication to the project. Ideally, this program would allow for full-time coverage to best accommodate patient availability and follow-up. Administrative costs included costs supporting the involvement of the project leaders in administering the program. These activities included securing agreements with project collaborators, delivering presentations to various groups, addressing day-to-day project issues. Technology costs were largely borne by the ePHR vendor. The retail cost of the ER-Card® ePHR is approximately $98 per year; however this cost was waived for program participants who may utilize the ePHR at no cost, for an indefinite time period.


Getting Started With This Program: Three essential elements in promoting the effective use of ePHR technologies and pharmacy care activities post-hospitalization are recommended:

  • Recruiting patients during or immediately following a hospital stay is problematic. It may likely be more effective to target patients at high risk of hospitalization, and set them up as ePHR users when in relatively stable health.
  • Patients may likely be more agreeable to the intervention if it is recommended by the physician. The innovation / intervention was often seen by patients as supplementary to care and/or as a research study. Incorporating this innovation as an optional yet promoted aspect of care may yield greater rates of participation.
  • The nature of information compiling and sharing associated with the ePHR presents several considerations relative to HIPAA and IRB concerns. Innovators should be prepared to allocate resources and expertise to addressing these concerns.

Sustaining This Program: Project leaders are pursuing additional funding to continue use of the ePHR and pharmacy services intervention in the context of care transitions and in other contexts (e.g., among patients having mental health and disability-related health care challenges). Project leaders suggest that inter-organizational dynamics and priorities will continue to influence support for the program. Additionally, patient acceptance of the role of the pharmacist in novel contexts is expected to increase, as will patients' acceptance of information technologies within the home.

Other Considerations and Lessons: The interest in the program among pharmacists was strong. The program was the subject of a URI newsletter feature, which led to the American Society of Health-System Pharmacists highlighting the program in a published news article. Program leaders were contacted by several hospital-based pharmacists who were tasked with implementing similar programs, as their institutions prepare for becoming an Accountable Care Organization. Considerations and lessons shared with these pharmacists included:

  • Need to consider staff safety when conducting home visits. Pharmacists encountered challenging neighborhood environments.
  • Having a pharmacist perform recruiting and scheduling tasks may be unnecessarily expensive; other staff may be able to perform some of these functions.
  • Many patients can be reluctant to agree to the home visit, and others do not deem the medication review to be important. Gaining the active engagement of such patients is a significant challenge.


    1. Ernst FR, Grizzle AJ. Drug-related morbidity and mortality: updating the cost-of-illness model. J Am Pharm Assoc. 2001 Mar-Apr;41(2):192-9.
    2. Shrank WH, Asch SM, Adams J, et al. The Quality of Pharmacologic Care for Adults in the United States. Med Care 2006 Oct;44(10):936-45.
    3. Coleman EA, Smith JD, Raha D, Min SJ. Post-hospital Medication Discrepancies: Prevalence and Contributing Factors. Arch Intern Med. 2005; 165:1842-1847.
    4. Kaelber DC, Jha AK, Johnston D, Middleton B, Bates DW. A research agenda for personal health records (PHRs). J Am Med Inform Assoc. 2008 Nov-Dec;15(6):729-36.

Tech4Impact Care Transitions Diffusion Grants Program