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The Discharge Companion Program: An Interprofessional Collaboration in Transitional Care Model Delivery

SinfoníaRx, Tucson, AZ 85701, USA
Pharmacy Quality Alliance, Alexandra, VA 22315, USA
College of Pharmacy, University of Arizona, Tucson, AZ 85721, USA
Tabula Rasa Healthcare, Tucson, AZ 85701, USA
Allergan, Irvine, CA 92612, USA
Author to whom correspondence should be addressed.
Pharmacy 2019, 7(2), 68;
Received: 25 April 2019 / Revised: 6 June 2019 / Accepted: 17 June 2019 / Published: 19 June 2019
(This article belongs to the Section Pharmacy Education and Student / Practitioner Training)
PDF [653 KB, uploaded 19 June 2019]


To reduce readmission rates and avoid financial penalties from the Centers for Medicare and Medicaid Services, hospitals are seeking to implement innovative transitions of care (TOC) programs. This retrospective study evaluated the Discharge Companion Program (DCP), a pharmacist- and nurse-coordinated interprofessional, collaborative TOC program. Adult patients (18 years and older) from a single hospital, discharged with at least one qualifying diagnosis, were eligible for this service. The hospital transitional care coordinator nurse referred qualified patients to the DCP nurse coordinator, who scheduled telephonic medication therapy management (MTM) reviews with the DCP pharmacist at one- and three-weeks postdischarge. Hospital records and DCP documentation were reviewed to describe respective interventions and assess the impact on 30-day readmissions. A total of 456 patients were referred to the DCP between 31 August, 2015 and 7 September, 2016. Of the 340 patients who participated (DCP group), 44 (13%) compared to 17% (n = 20) of the usual care, were readmitted within 30-days postdischarge. The DCP pharmacists conducted 1242 clinical interventions with participants, demonstrating the benefits of an interprofessional TOC model involving multiple, pharmacist-delivered MTM intervention touchpoints within 30 days post-hospital discharge. View Full-Text
Keywords: interprofessional collaboration; pharmacist; nurse; transition-of-care; readmission interprofessional collaboration; pharmacist; nurse; transition-of-care; readmission

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Bingham, J.; Campbell, P.; Schussel, K.; Taylor, A.M.; Boesen, K.; Harrington, A.; Leal, S.; Warholak, T. The Discharge Companion Program: An Interprofessional Collaboration in Transitional Care Model Delivery. Pharmacy 2019, 7, 68.

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