Pharmacy Academy News - January 2026
Transitions of care occur when patients move between healthcare settings or providers and represent a period of heightened vulnerability for medical errors. Medication‑related problems are particularly common during these transitions. Nearly 20% of Medicare beneficiaries are readmitted to the hospital within 30 days of discharge, and up to 80% of patients experience at least one medication discrepancy at the time of hospital discharge1,2. These adverse outcomes are multifactorial in origin, with communication failures frequently identified as a contributing factor. Common challenges include delayed or incomplete communication between inpatient and outpatient providers, inaccurate medication reconciliation, and insufficient patient or caregiver understanding of the disease process, newly prescribed medications, or post‑discharge care plans 2. Pharmacists possess the clinical training and expertise necessary to identify, prevent, and resolve medication‑related issues, positioning them to play a critical role in reducing hospital readmissions and improving the safety and quality of care transitions.
A research study conducted by an interprofessional team from West Virginia University (WVU), including Pharmacy Academy member Gina Baugh, PharmD, FNAP, examined the impact of an interprofessional huddle embedded within a telemedicine transitions‑of‑care clinic serving a rural Appalachian community. Pre‑licensure and early clinical students from medicine, pharmacy, physical therapy, physician assistant studies, and public health participated in the program. Prior to each telehealth encounter, students engaged in a structured interprofessional huddle to review hospitalization details, identify gaps in care and barriers to access, and develop coordinated, team‑based interventions. Students then participated in live telemedicine visits, assuming profession‑specific responsibilities such as medication reconciliation and patient education.3
Participation in the huddles was associated with improvements across multiple interprofessional competency domains, as measured by the Interprofessional Collaborative Competencies Attainment Survey (ICCAS). Students also reported increased appreciation for the role of telemedicine in addressing rural health disparities and for the value of interprofessional collaboration in virtual care delivery. 3
A separate publication evaluated the program’s impact on patient outcomes. Adult patients (n=16) with uncontrolled chronic conditions, including hypertension, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF), were enrolled following hospital discharge. Care was delivered by an interprofessional team consisting of physicians, pharmacists, and the health‑professions students listed above, with patients participating in the program for an average of three months. Despite the small cohort size, outcomes were notable: 12.5% of patients experienced a hospital readmission or emergency department visit within 30 days of discharge; among patients with diabetes, mean hemoglobin A1c levels decreased from 11.0% to 8.1%; and blood pressure control improved in most patients with hypertension. Additionally, the program yielded an estimated total cost savings of $3,144 for the cohort, largely attributable to reduced travel requirements and avoidance of in‑person visits. 4
Collectively, this WVU initiative highlights the meaningful contributions pharmacists and pharmacy students can make as integral members of interprofessional telehealth transitions‑of‑care teams, particularly in rural and underserved communities.
1. Community-based care transitions program. Centers for Medicare & Medicaid Services. Updated March 24, 2022. Accessed January 20, 2026. https://innovation.cms.gov/innovation-models/cctp
2. Quick safety issue 26: transitions of care: managing medications. The Joint Commission. Updated April 2022. Accessed January 20, 2026. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-26-transitions-of-care-managing-medications/#.Y-maqcfMJPZ
3. Thayer J, Miller B, Liriano MM, Hoffman K, Thompson J, Baugh G, Sizemore J. The post-hospitalization huddle: an interprofessional education model for clinical telemedicine. J Interprofessional Educ Pract. 2025;41:100774. https://doi.org/10.1016/j.xjep.2025.100774.
4. Thayer J, Miller B, Liriano MM, Hoffman K, Baugh G, Sizemore J. Intensive telemedicine transitions of care clinic: a prospective feasibility study of a novel ambulatory model serving Appalachian patients. J Appalach Health. 2025;7(3): 95–104. https://doi.org/10.13023/jah.0703.07.
