for people ages 18 years and up (full criteria)
study started
estimated completion
Jan Hirsch



Many hospitals and medical groups have developed transitions of care (TOC) programs or procedures in an attempt to reduce hospital readmission and reutilization rates of patients discharged from the hospital. As healthcare's most accessible practitioners, Community Pharmacists have a unique opportunity to assist with reducing unnecessary hospital re-utilization (re-admissions and emergency department visits) after hospital discharge. The purpose of this study is to conduct and evaluate the implementation of a Community Pharmacy-based Transitions of Care (TOC) Program for high-risk post-discharge patients of PIH Health Hospital-Whittier (PIH). The primary objective will be to compare the proportion of patients with hospital re-utilization (readmission, observation status, ED visits) during 30-days post hospital discharge between patients randomly assigned to the PHARMD-TOC group vs. the historic rate at PIH. Secondary analyses will examine differences between groups and describe implementation details of the PHARMD-TOC model of patient care.


Patients With Moderate to High Risk of Hospital Readmission PharmD TOC PHARMD-TOC i


You can join if…

Open to people ages 18 years and up

    • Admission LACE Score: in moderate range (5 to 9) And
  • Taking high risk medication(s): anticoagulants, insulin, oral antiplatelet agents, oral hypoglycemic agents, opioid analgesics, digoxin Or Taking at least 5 medications

AND have one of following: CHF, COPD, Asthma, Pneumonia, Diabetes, ESRD, Schizophrenia, Bi-Polar, Dizziness, History of Falls


  • Medical or Surgical Unit patients
  • Age > 18 years
  • Being discharged to home (with or without Home Health services)
  • English and/or Spanish speaking
  • Will have access to a telephone post-discharge
  • Ability to give consent
  • Patient admitted to hospital through the emergency department, as a direct admission or as a transfer, or as an elective surgery patient

You CAN'T join if...

    • Patients with observation status
  • Caremore Health Plan patients (Caremore has a separate post-discharge program)
  • Patients discharged and followed up by the PIH Coumadin Clinic
  • Patients discharged to Residential MD House Calls program
  • Patients discharged to Skilled Nursing Facility
  • Anyone with planned readmissions
  • Obstetrics patients
  • Hospice patients
  • Oncology patients
  • Anyone who does not meet provisions of protocol
  • Anyone unwilling or unable to give consent for study procedures and data access

Lead Scientist

  • Jan Hirsch
    Nurse Practitioner, Reproductive Medicine. Authored (or co-authored) 49 research publications


not yet accepting patients
Start Date
Completion Date
University of California, San Diego
Study Type
Last Updated