# Preventing Medication-Related Problems in Care Transitions to Skilled Nursing Facilities

> **NIH AHRQ R01** · UNIVERSITY OF WASHINGTON · 2024 · $400,000

## Abstract

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.

## Key facts

- **NIH application ID:** 10896943
- **Project number:** 5R01HS027805-05
- **Recipient organization:** UNIVERSITY OF WASHINGTON
- **Principal Investigator:** Giana Davidson
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2024
- **Award amount:** $400,000
- **Award type:** 5
- **Project period:** 2020-09-30 → 2025-10-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10896943

## Citation

> US National Institutes of Health, RePORTER application 10896943, Preventing Medication-Related Problems in Care Transitions to Skilled Nursing Facilities (5R01HS027805-05). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10896943. Licensed CC0.

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