Health disparities remain one of the most persistent and complex challenges in the United States healthcare system. Differences in outcomes driven by social determinants of health (SDOH), such as socioeconomic status, race and ethnicity, geography, language barriers, and access to care, continue to disproportionately affect vulnerable populations. While no single intervention can eliminate these inequities, pharmacist-led transitions of care programs represent a powerful, often underutilized opportunity to reduce gaps, improve outcomes, and create a more equitable healthcare experience.
Transitions of care refer to the movement of patients between hospital, post-acute, and home settings, a period associated with elevated risk for medication errors, readmissions, and care gaps. These moments often feature heightened clinical risk. For example, it’s estimated that around 60% of medication errors happen during transitions of care, especially when sharing medical information across multiple care teams.
During this time, medication changes are frequent, communication breakdowns are common, and patients are often overwhelmed. For individuals already facing barriers to medication adherence such as limited health literacy, unstable housing, or lack of consistent primary care access, these risks are further amplified.
By embedding pharmacists into transitions of care workflows, healthcare organizations can address medication-related drivers of disparities at one of the most critical points in the care journey.
Understanding health disparities in transitions of care
Health disparities often emerge most clearly during care transitions. Hospital discharge instructions may be confusing or incomplete. Medication regimens can change rapidly, with new prescriptions added, others discontinued, and dosages adjusted as part of medication reconciliation efforts. Patients may leave the hospital without fully understanding why changes were made or how to safely manage their medications at home.
For patients from underserved communities, these challenges are compounded by structural and social factors. This means:
- Limited access to transportation can delay prescription fills
- Language barriers can prevent patients from understanding discharge instructions
- Financial constraints may force difficult choices between medications and basic needs
- Cognitive impairment, lack of caregiver support, and fragmented follow-up care further increase the risk of medication errors and adverse events
And not to mention, with 29% of pharmacy closures in the U.S., pharmacy deserts have been further exacerbated, especially in rural and underserved areas.
These failures in transitions of care contribute directly to higher readmission rates, poorer chronic disease control, and avoidable emergency department visits, which are all outcomes that disproportionately affect marginalized populations. These outcomes are also closely monitored in value-based care and Star Ratings programs. Addressing disparities, therefore, requires targeted interventions that recognize transitions of care as a pivotal moment for equity-focused clinical support.
3 reasons why pharmacist-led transitions of care matter
Pharmacists are essential when it comes to addressing medication-related inequities during transitions of care. Their expertise in polypharmacy and medication management, combined with their accessibility and patient-centered training, allows them to identify risks that may otherwise go unnoticed by other health care professionals.
Pharmacy transitions of care programs focus on maintaining medication continuity, accuracy, and understanding as patients move between care settings. This includes comprehensive medication reconciliation, identification of duplications or omissions, patient education, and coordination with providers and caregivers.
When implemented effectively, pharmacy transitions of care go beyond preventing errors; they create a safety net for patients navigating a complex healthcare system. For vulnerable populations, this safety net can be the difference between recovery and readmission.
1. Addressing social determinants through medication management
Reducing health disparities requires acknowledging the role of social determinants of health (SDOH). SDOH are the conditions that people are born, grow, live, and work in, as well as their access to money and resources. These factors have a significant influence on health inequities, but pharmacy transitions of care offer a practical pathway to address these factors in real time.
During post-discharge medication reviews, pharmacists can uncover barriers such as affordability issues, transportation challenges, or confusion about dosing schedules. Identifying these obstacles allows care teams to intervene early by recommending lower-cost alternatives, coordinating mail-order delivery, simplifying regimens, or connecting patients with community resources.
Pharmacists can also tailor education to a patient’s level of health literacy and preferred language, improving comprehension and adherence. This individualized approach is especially critical for patients managing multiple chronic conditions, where medication complexity often adds to disparities.
2. Improving communication across the care continuum
One of the most significant contributors to disparities in transitions of care is fragmented communication. Discharge summaries may not reach primary care providers in a timely manner, and medication changes may not be clearly documented or explained.
Pharmacy transitions of care programs help close these gaps by acting as a clinical bridge between settings. Pharmacists can verify medication lists across sources, communicate changes to providers, and make sure care plans are aligned. This coordination reduces confusion, improves continuity, and supports safer handoffs, particularly for patients who receive care from multiple providers or health systems.
In short, clear, consistent communication is an equity issue. Patients are less likely to fall through the cracks due to systemic inefficiencies when information flows reliably.
3. Advancing equity through targeted interventions
Data-driven pharmacy transitions of care programs allow organizations to identify patients at the highest risk for adverse outcomes. These may include individuals with multiple comorbidities, recent hospitalizations, or documented medication adherence challenges.
By prioritizing outreach to high-risk populations, pharmacists can focus their resources where they are needed most. This targeted approach supports equity by proactively addressing the needs of patients who historically experience poorer outcomes.
Additionally, pharmacy-led interventions can help close gaps in quality measures tied to health equity, such as medication adherence, chronic disease control, and hospital readmissions. Improving these metrics not only benefits patients but also supports health systems in advancing value-based care goals.
How technology can help scale health equity outcomes
Modern technology plays a critical role in expanding the reach of pharmacy transitions of care. Digital platforms enable pharmacists to access comprehensive medication histories, identify discrepancies, and document interventions efficiently.
Streamlining care with Alliance by Aspen RxHealth
Designed for in-house care teams, our SaaS solution, Alliance by Aspen RxHealth, supports transitions of care by:
- Centralizing data: Gathering disparate information into a single source of truth.
- Standardizing documentation: Ensuring consistency across all patient interactions.
- Enabling collaboration: Allowing seamless communication across multidisciplinary care teams.
- Scaling outreach: Deploying pharmacist-led models that deliver timely post-discharge engagement without requiring in-person visits.
Overcoming access barriers via remote services
Remote pharmacy services further reduce access barriers by connecting patients with pharmacists regardless of geography or mobility limitations. Our web-based medication management platform, BeWell, gives our nationwide network of remote pharmacists the ability to:
- Eliminate pharmacy deserts: Provide expert care to rural or underserved areas.
- Improve accessibility: Assist patients with limited transportation or mobility challenges.
- Support diversity: Offer consultations in multiple languages to bridge communication gaps.
- Provide flexibility: Make it easier for individuals from diverse backgrounds to receive care on their own terms.
Personalizing pharmacy care at scale
When paired with structured workflows and clinical decision support, technology delivers consistency while allowing pharmacists to deliver personalized, culturally responsive care. Scalable pharmacy transitions of care models make it possible to address disparities across large and diverse populations.
Alliance by Aspen RxHealth enhances this impact by equipping in-house teams with configurable workflows, real-time insights, and quality-aligned reporting, making equitable transitions of care achievable at scale.
Pharmacy technology to support patients and caregivers
Equitable transitions of care also depend on patient and caregiver empowerment. Pharmacists build trust and safety by:
- Educating patients: Helping individuals understand medications and side effects.
- Engaging caregivers: Providing essential education for those supporting patients with cognitive impairments or complex regimens.
- Building trust: Establishing open communication with communities that may have historically experienced mistrust in the healthcare system.
Measuring success beyond readmissions
While reduced readmission rates are a common measure of success, the true impact of pharmacy transitions of care extends further. Equity-focused outcomes include improved medication adherence, better chronic disease management, increased patient satisfaction, and reduced disparities in care quality.
Tracking these outcomes helps organizations understand how pharmacy interventions contribute to broader health equity goals. Continuous evaluation also allows programs to adapt and refine strategies based on patient needs and emerging disparities.
A path forward for health equity within the transitions of care process
Reducing health disparities requires intentional design, interdisciplinary collaboration, and sustained commitment. Pharmacist-led transitions of care offer a tangible, evidence-based strategy to advance equity by addressing medication-related risks at a critical juncture in care.
As healthcare continues to shift toward value-based models, the role of pharmacists in transitions of care will only become more important. By integrating technology and pharmacy expertise into discharge planning, follow-up care, and patient engagement efforts, organizations can create more equitable outcomes while improving quality and efficiency.
Pharmacist-led transitions of care are not only about medications; they are about people. It represents an opportunity to meet patients where they are, address systemic barriers, and make sure that every individual has the support needed to navigate their healthcare journey safely and confidently.
To learn more about how Aspen RxHealth supports equitable transitions of care, contact us for a demo today.
