Intalere Member Best Practice Spotlight – Improving Transition of Care in Nursing Facilities: Pharmacists Supporting the Interdisciplinary Team – Southwest Medical Pharmacy (part of OptumCare)


OptumCare strives to provide innovative healthcare to its patient population and wanted to develop a program that would help ease the process for the patient as they transitioned into and out of the long-term care setting. A pilot project was developed to show the benefits of having a pharmacist involved in the skilled nursing facility (SNF) interdisciplinary team for OptumCare’s Medicare Advantage patients.


The pharmacy team supported the medication reconciliation process by taking a patient-centered approach. This included providing transition of care services on admission and prior to discharge. Admission services included a face-to-face patient interview, robust review of transferring documents, comprehensive medication review and providing recommendations to the physician on findings. Discharge services included review of discharge prescriptions, medication review, patient counseling and post-discharge follow-up call services.


Pharmacists completed 2,454 patient encounters and 4,655 interventions in 2018. On average, pharmacists found 13.2% of the total interventions made were identified as high-risk interventions with the majority of those interventions due to omission of therapy. The program had a calculated ROI of 4:1. The patients were surveyed post-discharge and the results had an average patient satisfaction score of 80.4. In addition, pharmacist support assisted in the completion of the Medication Reconciliation Post Discharge measure (1111F) which occurred 899 times in 2018.

About Southwest Medical Pharmacy & Home Medical Equipment

Southwest Medical Pharmacy (part of OptumCare) provides operational and clinical services in a variety of settings including long-term care, hospice and home infusion. The Clinical Pharmacy team completes traditional nursing home consulting, surgery center consulting and transition of care services in multiple nursing facilities in Las Vegas, Nev.

Check out the project video and view the Southwest Medical Pharmacy page in the 2019 Intalere Best Practices Compendium.

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