ABSTRACT The transition of care from acute-care hospital to skilled nursing facility (SNF) is a poorly coordinated process that exposes some of our most vulnerable patients to a high risk of complications, emotional distress, and hospital readmissions. Preventable, medication-related problems are a common result of this poorly coordinated care and are a major driver of the adverse outcomes that patients experience following hospital discharge. The standard discharge processes currently required by The Joint Commission include hospital staff completing a paper-based discharge summary and medication reconciliation form. Despite this process, up to 75% of patients admitted to SNFs have at least one medication discrepancy between the SNF admitting orders and the hospital discharge plan. In 2014, a Washington State collaborative led by the University of Washington and including stakeholders from over 50 SNFs and hospitals ─ the Improving Nursing Facility Outcomes using Real-Time Metrics (INFORM) collaborative ─ was formed to address this and other SNF-related quality of care issues. To reduce the likelihood of medication-related problems during care transitions, INFORM stakeholders developed the Pharmacy Integrated Transitions (PIT) program, which improves the standard transition process by adding: 1) a structured, synchronous “warm-handoff” between clinical teams at the hospital and the SNF, incorporating patients and their families or caregivers, by using commonly available teleconferencing; and 2) a coordinating transitional pharmacist to reconcile, adjust, and monitor medications during and after discharge from the hospital. To determine the effectiveness of the PIT program across a heterogenous healthcare delivery systems, we propose a cluster randomized trial comparing the PIT program with The Joint Commission care transition process for patients transitioning from four diverse hospitals within one health system to a network of 16 SNFs. This system-level randomized controlled trial will test the effectiveness of the PIT program in reducing medication- related problems (MRPs) and improving patient-, family-, and caregiver-reported measures of the quality of care transition. This study aims to: 1) compare the effectiveness of the Pharmacy Integrated Transitions (PIT) program and the Joint Commission transition process on MRPs, and 2) compare patient and caregiver-reported measures of quality of communication and care coordination between the PIT program and the Joint Commission transition process. This study addresses a critical evidence gap that impacts the care of millions of people and is primed for broader national uptake, as most hospitals and SNFs already employ the necessary key personnel, resources, and technology, requiring only redeployment and training.