The Cost of a Broken Handoff: Why Medication Management Must Follow Patients
A patient in her 70s is discharged from the hospital to a skilled nursing facility with several changes to her medication regimen. The transfer paperwork lists them, but everyone on the receiving end is new to her care. One change is missed in the handoff, and the facility continues a medication the hospital had stopped.
Whether the move is hospital to facility, hospital to home, or facility to facility, transitions of care carry a high risk of medication errors, which can lead to avoidable readmissions.
This article explores how continuity of care helps catch medication discrepancies at these critical moments, before they lead to harm and higher costs.
The “Handoff” as the Point of Failure
Care transitions aren’t inherently dangerous, but the risk of error increases when they are treated as handoffs: where one provider’s responsibility ends, the next begins, and the patient’s information may not be transferred in full.
Hospitals, facilities, and pharmacies often run on different EMR systems that don’t communicate well, so each new team may start with an incomplete picture. Discharge lists may carry discontinued medications or omit newly started medications. Additionally, short-term therapies like antibiotics can arrive without stop dates, all of which complicate medication reconciliation.
In a 2024 study published in the Journal of American Medical Directors Association, 98% of older adults discharged home from a post-acute care facility had at least one medication discrepancy at the 7-day follow-up. Discrepancies involving potentially inappropriate medications (PIMs) in older adults under the Beers Criteria were high frequency, with 92% of patients affected and a range of 2 to 6 discrepancies per patient.
Make Continuity of Care the Default
A care transition should be a continuation of high-level patient management. Even as care settings and providers change, medication management should stay constant, with one complete medication record and one pharmacy team following the patient through every move.
Consider the woman in her 70s who was discharged to a skilled nursing facility: had a pharmacy team with her full medical history been reviewing the transfer, the discontinued medication would have been caught on day one, not discovered days later.
In a 2025 study published in Innovations in Pharmacy, a pharmacy team at a single clinic called Medicare and Medicaid patients within 48 hours of discharge to review their medications and schedule a doctor’s visit. Across nearly 300 hospital stays, patients who completed a call were readmitted within 30 days at half the rate of those who did not (16.9% vs. 34.7%).
Medication management that stays continuous across every setting, with each change reviewed and reconciled, is what protects patients and controls costs.
The Financial Stakes of Fragmented Medication Management
Gaps in medication management during transitions carry direct financial consequences, and at Medicare’s scale, those costs add up quickly.
Medicare readmissions totaled $36.2 billion in 2020, about $18,100 each, according to the Agency for Healthcare Research and Quality (AHRQ).
Estimates of how many readmissions are medication-related vary. A 2018 systematic review in the Journal of the American Geriatrics Society put the median at 21%, with roughly two-thirds of those potentially preventable.
For health plans, readmissions drive total cost of care and avoidable utilization, particularly among medically complex patients. Hospitals and skilled nursing facilities are also held accountable, with Medicare tying a portion of their payments to 30-day readmission rates.
Intervening at the right time improves outcomes and lowers costs. In a 2023 study published in the Journal of the American Pharmacists Association, a pharmacist-led transitions of care program for patients at high risk of readmission reduced 30-day readmissions by 36% and emergency department visits by 75%.
Clarest Path Is Built to Move with Patients
Whether a patient leaves the hospital, enters a facility, or returns home, Clarest Path carries one continuous medication record and the same clinical team through every move. Its real-time engine flags medication changes and new risks as they happen, and Clarest’s 600+ nurses and pharmacists follow up through an AI-guided live call center.
The platform pairs intelligent automation with a human touch to make sure patients’ medication needs are addressed. Whether the issue is a refill, a medication change, or a barrier to pharmacy pickup, Clarest’s team proactively closes the gap, supported by electronic integrations across the healthcare system.
Protecting Patients at Every Transition
Every move between hospitals, facilities and home is a chance for medication errors to slip through. With continuous medication management and oversight, discrepancies can be caught on day one, keeping patients safe and out of the emergency room. To learn more about how Clarest Path follows patients across every care setting, schedule a meeting with our team.