In addition to medication counseling and support, the Healthy Transitions program follows patients for 30 days to provide ongoing guidance around chronic illnesses, safety, advance-care planning and other potential readmission risk factors. At the end of 30 days, patients are referred back into the appropriate care-management programs at SCAN or Lakewood IPA.

"Our patients have been very open to having the home visit. The comprehensive counseling, support and assessment from the pharmacist are an asset to the physician and the case managers in the continued coordination of care for these high-risk members," said Robin Tufono, director of outreach programs at Coast.

Up and running for over five months, the Healthy Transitions program is already having a positive impact. "We have clearly seen instances when potential readmissions were avoided," said Sylvia Hastanan, director of clinical operations at Dovetail Health. "In one case, for example, a patient was missing a prescription for a critical antibiotic medication required to treat a urinary tract infection."

Source: SCAN Health Plan and Lakewood IPA