Nurse Practitioner-Led Care Transitions Program: Medication Management From Skilled Nursing Facility to Home


      • Transitions of care are especially challenging for the geriatric population, who often have multiple chronic conditions.
      • A large number of patients transitioning from skilled nursing facilities to home experience adverse events related to medications.
      • Medication reconciliation is an integral part of transitional care to help reduce adverse events.


      Transitions of care are high risk for patients, particularly for the geriatric population transitioning from a skilled nursing facility to home. Medication events during care transitions are common, often resulting in adverse patient outcomes. This report synthesizes available research on skilled nursing facility-to-home transitions, shares practices from a current nurse practitioner-led transitional care program, provides case examples, outlines best practice recommendations, and identifies future research and education needs.


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      Natalie Mohammad, MSN, AGPCNP-BC, is a nurse practitioner at Mayo Clinic, Rochester, Minnesota, and can be contacted at [email protected] .


      Molly DiTommaso, DNP, AGPCNP-BC, and Sara Jacobsen, MSN, AGACNP-BC, are nurse practitioners at Mayo Clinic, Rochester, Minnesota.