Transitions of Care and Patient Follow-Up

Michael A. Evans, BS, RPh, describes why patient follow-up is necessary during transitions of care scenarios following the initiation of treatment with an anticoagulant. Warfarin therapy requires close, regular monitoring by a patient’s healthcare team; thus, the management of patients taking warfarin can be a challenge, especially during transitions of care, notes Mr Evans. In contrast, he adds, the management of patients taking direct-acting oral anticoagulants is comparatively easier, as these agents do not require routine monitoring.

Regardless of which treatment option is prescribed for a patient, patient follow-up is important during transitions of care scenarios because it can help prevent drug-related adverse events and thromboembolic complications, says Mr Evans. Patients and their caregivers need to be educated about the purpose of their treatment, the potential for side effects and drug-drug interactions, and the importance of taking their treatment as prescribed. The nature and frequency of follow-up care should be individualized following an assessment by a clinician, he suggests.

Institutions should establish protocols for appropriate follow-up care, which includes follow-up phone calls. The individual that makes the follow-up phone calls with the patient following a transition of care need not be the physician. Rather, any member of a patient’s multidisciplinary care team (eg, a nurse, pharmacist, assistant) can make follow-up phone calls.