Central TOC
The University of Michigan Central Transitions of Care service specializes in providing pharmaceutical care for adult patients at high risk for readmission after hospital discharge. Our clinical pharmacists proactively contact eligible patients to conduct comprehensive transitions of care (TOC) visits. During these phone visits, we perform thorough medication reviews, clinical interventions, and develop monitoring plans tailored to each patient’s needs. Additionally, we provide patient and caregiver education during the TOC phone visits, empowering them to manage their medications and health effectively at home. The clinical pharmacists collaborate closely with providers by sending them detailed recommendations prior to the patient’s post-discharge visit, ensuring safe, effective, and evidence-based drug therapy. Our goal is to identify and resolve medication-related problems, ultimately improving patient care and reducing the risk of readmission. The central transitions of care service enhances the transition of care from hospital to home, promoting continuity of care and optimal patient outcomes. This clinic supports pharmacy learners at multiple levels, with rotations available for IPPE and APPE students as well as PGY1 and PGY2 pharmacy residents.
Geriatric TOC
The University of Michigan Geriatric Transitions of Care service specializes in providing pharmaceutical care for geriatric patients following hospital discharge. Our clinical pharmacists proactively contact patients who receive primary care at the Turner Geriatric Clinic to conduct comprehensive transitions of care visits. During these visits, we perform thorough medication reviews and assess medical conditions to identify patients who may require earlier medical or social work services. We develop clinical interventions, recommendations, and monitoring plans tailored to each patient’s needs, which are sent to the provider prior to the patient’s post-discharge visit. Our pharmacists review therapeutic regimens to ensure appropriateness, make clinical recommendations to improve patient care, and optimize medication regimens. Patient and caregiver education are integral parts of our service, provided during the visits to empower patients to manage their health effectively. Through exclusive phone communication, our service aims to enhance the transition of care from the hospital or rehab facilities to primary care for the geriatric population, promoting continuity of care and reducing risk of readmission in this vulnerable patient population. This clinic supports pharmacy learners at multiple levels, with rotations available for IPPE and APPE students as well as PGY1 and PGY2 pharmacy residents.
Cardiology and Heart Failure TOC
The University of Michigan Cardiology and Heart Failure Transitions of Care service focuses primarily on cardiovascular disorders such as heart failure, acute coronary syndrome/coronary artery disease, stroke/transient ischemic attack, arrhythmias, anticoagulation, hypertension, and hyperlipidemia. Additionally, as part of a comprehensive review, we address secondary focuses including endocrine disorders, respiratory disorders, neurologic disorders, and other conditions as needed based on patient presentation. Our service provides clinical recommendations to providers to enhance patient care and address medication-related problems. We offer patient and caregiver education during transitions of care phone visits, with a focus on improving the transition from hospital to home and preventing hospital readmissions. Overall, our service is dedicated to optimizing patient outcomes and ensuring seamless transitions of care for individuals with complex medical needs. This clinic supports pharmacy learners at multiple levels, with rotations available for P4 APPE students as well as PGY1 and PGY2 pharmacy residents.
Ypsilanti Health Center TOC
The University of Michigan Ypsilanti Health Center Transitions of Care service specializes in providing pharmaceutical care for adult patients at high risk for readmission following hospital discharge. During these visits, the clinical pharmacist performs thorough medication reviews and determines clinical interventions, recommendations, and monitoring plans tailored to each patient’s needs. These recommendations are discussed with the medical resident and medical attending during the clinic visit. Our pharmacists review therapeutic regimens to ensure safe, effective, and evidence-based drug therapy, providing clinical recommendations to improve patient care and resolve any identified medication-related problems. Additionally, we offer patient and caregiver education during the TOC appointments, empowering them to manage their medications and health effectively at home. Overall, our service aims to enhance the transition of care from hospital to home, promoting continuity of care and reducing risk of readmission. This clinic supports the PGY2 ambulatory care residents, fostering the development of expertise in transitions of care services.
Chelsea Hospital Heart Failure (HF) Transitions of Care (TOC)
The Chelsea Hospital Heart Failure (HF) Transitions of Care (TOC) service offers comprehensive virtual visits for discharged HF patients aimed at ensuring a smooth transition from hospital to home care. These virtual visits are conducted at 2-weeks post-discharge and 4-weeks post-discharge, providing vital support and follow-up care. Key services provided include HF-medication reconciliation and optimization, assessment of home BP/HR, HF-related symptoms, side effects, medication adherence, and lifestyle factors, as well as providing patient education. The Chelsea Hospital HF TOC program consists of a multidisciplinary team that provides personalized care to optimize the health and well-being of heart failure patients as they transition from hospital to home.
