Project Summary Transitions of care (TOC) from the hospital to primary care setting presents a vulnerable period for the occurrence of adverse drug events (ADEs) which can result in hospital readmission. ADEs are the most common adverse event occurring post-discharge and are often preventable. Given their training and expertise in medications, pharmacists can play a crucial role in improving the safety and quality of care delivered to patients during TOC. When implemented in a consistent, high-fidelity manner, pharmacist-provided comprehensive medication management (CMM) provided outside of the TOC process has been shown to improve hospital readmission rates, clinical outcomes, and health system spending. What remains unknown is how to effectively and efficiently integrate CMM services into TOC workflows in a primary care setting for patients recently discharged from the hospital. Furthermore, the implementation of these processes in a population with high social determinants of health (SDOH) which have significant barriers that may prevent timely follow-up care is systematically understudied in the literature. This study uses an adapted Consolidated Framework for Implementation Research (CFIR) and the RE-AIM model to evaluate the implementation of pharmacist-led CMM in a TOC. To facilitate communication between the hospital and primary care setting, this workflow will utilize an automated electronic alert system (EAS) to notify sites of the need for CMM following a hospital visit. Although studies have examined the effect of implementing an EAS on improvements in care coordination with primary care providers, few studies have utilized EAS to delivery CMM. The research team will conduct this study in collaboration with the Minnesota Federally Qualified Health Center Urban Health Network (FUHN) which operates as the nation’s first safety-net Accountable Care Organization. Aim 1 will identify facilitators and barriers to the implementation and adoption of CMM in a patient-centered TOC workflow. This aim uses a formative evaluation approach to obtain the perspectives of pharmacists, providers, clinic leadership, and care coordinators to uncover barriers and facilitators to the implementation of CMM into TOC workflow. Aim 2 will evaluate the implementation outcomes of implementing CMM into a patient-centered TOC workflow. This aim uses an observational study design with Medicaid claims and electronic health record (EHR) information to examine the reach, adoption, implementation, and maintenance of CMM in TOC employing the RE-AIM model. Aim 3 will focus on the efficacy component of the RE-AIM framework by evaluating the safety and effectiveness outcomes of incorporating CMM into a patient-centered TOC workflow by evaluating the impact of CMM delivery on hospital readmission rates using Medicaid claims data and EHR information. Ultimately, the goal of this research is to generate key learnings that will facilitate the adoption and sustainability of CMM...