Virtually easing transitions of care

A new transitions of care model is helping high-risk patients in rural and remote areas avoid medication misadventure and hospital readmission through virtual pharmacist-led care.

After patients are discharged from the hospital, their transition back into the community can be high-risk, with significant potential for medicine-related harm. These risks are amplified significantly for rural communities due to sparse healthcare facilities, fragmented continuity of care and workforce shortages.  

The TIC TOC program in Western NSW is tackling these issues via a virtual model designed to support patients who are struggling to access care during vulnerable post-discharge periods.

The TIC TOC program will be further explored at the CPC26 conference later this month and is set to demonstrate how digital health and multidisciplinary collaboration can help bridge the gap between hospital and home. 

Ahead of the program’s launch, AP spoke with Linda Krogh, the Virtual Transitions-of-Care Stewardship Pharmacist with the Western NSW Local Health District and a current PhD candidate with the University of Sydney.

A virtual model of care

‘Transitions of care are deeply complex – even more so in remote settings due to factors such as distance, workforce, and community care,’ said Ms Krogh.

The CPC26 presentation will outline how the model translates into practice, including identifying high-risk patients, virtual medication reconciliation, multidisciplinary communication, and rapid coordination of Home Medicines Reviews (HMRs).

The Transitions of Care (ToC) Pharmacist role was introduced to provide virtual support across 19 towns, ensuring high-risk patients receive an optimal discharge and follow up, particularly when onsite pharmacy services are unavailable.

The layout of the model means that the ‘TOCS pharmacist monitors the patient’s hospital admission and supports the onsite or virtual clinical pharmacist to ensure all required discharge activities are completed,’ Ms Krogh said.

This includes reviewing electronic medical records to identify medicines that were commenced, ceased, changed, or continued during admission.

‘The role includes medication reconciliation, patient counselling, preparation of patient-friendly medication lists and direct communication with GPs and consultant pharmacists to facilitate timely post-discharge medication reviews,’ she said.

Through virtual work, pharmacists can connect hospital teams, patients, carers, and primary care providers across geographically disconnected areas. 

The risk in transitions

The severely limited access to GP services and healthcare facilities delays crucial follow-up appointments and check-ins after discharge. In most rural communities, locum professionals make up a significant part of the primary care workforce, creating significant challenges in ensuring continuity of care.

‘Patients are often discharged from hospitals located a long distance from home, which can delay access to medicines and follow-up post-discharge,’ Ms Krogh said.

Patients are identified as high risk for medicines misadventure and readmission based on criteria including  ‘use of high-risk medicines such as insulin, alongside a hospital readmission within the previous 6 months.’ 

‘These factors can increase the risk of medication discrepancies, misunderstandings, and adverse events once the patient returns home,’ she added.

Fast-tracking post-discharge HMRs

A key feature of the program is its focus on ensuring HMRs occur when they are needed – not when they are possible.

To ensure time-sensitive cases are addressed, the TOC pharmacist prepares a HMR referral for the patient’s GP before discharge. If the referral cannot be signed within a 48-hour window, the program activates the hospital-initiated HMR pathway, to avoid delays. 

‘The goal is for the post-discharge HMR to be completed within 10 days,’ Ms Krogh said.

Patients can choose whether they prefer their HMR conducted face-to-face or virtually, allowing referrals to be matched to credentialed pharmacists based on patient preference and location.

The TOCs pharmacist then books a GP appointment to ‘review the HMR recommendations and develop medication management plans, helping to close the loop on the patient’s transition of care,’ she said.

By clearly identifying patients as high-risk, reception staff are better able to triage appointment availability where demand exceeds capacity.

Connecting hospital and community care

A major strength of the TIC  TOC model is its ability to connect traditionally siloed parts of the healthcare system by facilitating communication between hospital clinicians, GPs, and community pharmacists – improving continuity of care throughout each patient’s journey. 

‘In rural towns where GP appointments are often booked out weeks in advance, this model ensures high-risk patients have their medications reviewed promptly by a pharmacist,’ Ms Krogh said.

With post-discharge HMRs frequently identifying medication misunderstandings, the early identification of medication-related issues also allows GP appointments to focus more efficiently on clinical decision-making and care planning.

The most common errors identified relate to patients’ misunderstanding of how to take their medicines following discharge, as well as short-term medicines that pose a point of confusion, such as tapered prednisolone regimens and analgesics.

‘In one case, a patient stopped taking an antihypertensive medication after overhearing nursing staff say it should be withheld during admission, not realising the change was only temporary,’ Ms Krogh said.

‘Another patient discharged with two antibiotics misunderstood the instructions and intended to take the medicines sequentially rather than concurrently.’ 

Multidisciplinary action

The TIC TOC model encapsulates a broader theme of multidisciplinary collaboration that will underpin CPC26. 

With healthcare systems championing the importance of coordinated care, this program demonstrates how pharmacists can play a central role in ensuring patient safety during transitions of care, particularly for vulnerable rural populations where limited access to timely healthcare poses challenges.

Further insights into the TIC TOC program and the virtual TOC’s pharmacist role will be shared during the CPC26 conference session, held between 29 – 31 May 2026 at the RACV Royal Pines Resort, Gold Coast.

Click here to register.