Closing the Gap Before It Becomes a Setback

“Our pharmacist consults are completed within 4–7 days—far exceeding the 30-day national allowance.”

— Brodie Wall, VICE PRESIDENT OF ANALYTICS

Every readmission has a story.

One review found that about 20% of patients experience adverse events after hospital discharge, with medication issues as the most common cause (Forster et al., 2003; Wuyts et al., 2025).

At Your Health Organization, we believe patients deserve a faster, safer handoff from hospital to home. That’s why we aim to reconcile medications for every high-risk patient within days of discharge. Today, our average pharmacist consult takes on AVERAGE 4–7 days—a significant improvement over the 30-day allowance set by NCQA’s national quality measure for Medication Reconciliation Post-Discharge (MRP) (NCQA, 2024).

A Proven Model, Adapted for Today

From VA Innovation to Community Care

The U.S. Veterans Health Administration (VHA) began embedding pharmacists into primary care teams in the 1970s, expanding the approach in the 1990s through the Patient Aligned Care Team (PACT) model. These pharmacists managed chronic conditions, adjusted medications under collaborative agreements, and became an essential safeguard against readmissions.

At Your Health, we launched our clinical pharmacy program in 2020, adapting this proven framework for our multi-payer, community-based environment, where patients frequently:

See multiple providers
Fill prescriptions at different pharmacies
Experience transitions between inpatient and outpatient settings without clean handoffs

Why It Matters for Patient Outcomes

Fewer Errors, Caught Sooner

Medication reconciliation identifies issues that might otherwise slip through during care transitions. Last quarter, Your Health pharmacists consistently uncovered errors, duplications, and therapy gaps—each one a potential readmission avoided.


Benchmark	Standard (Allowance)	Your Health
NCQA Quality Measure (MRP)	≤ 30 days	4-7 days
Best Practice (SCAN Health Plan)	≤ 7 days	4–7 days

Smoother Transitions from Hospital to Home

Research shows that pharmacist-led reconciliation after discharge reduces discrepancies and potential adverse drug events, with indicators of fewer ED visits and readmissions (Yahya et al., 2023).

For patients, that means a smoother recovery. For case managers and hospital partners, it means fewer last-minute calls, fewer chart corrections, and fewer unplanned readmissions to juggle.

“Our pharmacy team doesn’t just reconcile medications—we close the loop. Through follow-ups, we uncover when patients haven’t received their prescriptions and step in to coordinate to confirm receipt. This hands-on approach bridges gaps in care and ensures patients truly see and feel the benefits of our value-based program.”

— Melissa Jones, ACT Vice President, Your Health

Better Chronic Disease Control

While Your Health hasn’t published its own internal outcome data, landmark studies—such as the Asheville Project and American Heart Association statements—demonstrate that pharmacist involvement leads to improved A1c control, better adherence, and lower costs.

We observe these benefits daily in our patient care, especially among patients managing diabetes and cardiovascular disease.

The Bottom Line

By embedding pharmacists directly into primary care, Your Health closes medication gaps weeks ahead of national standards.

For patients, that means fewer medication setbacks and a safer recovery. For partners, it means smoother care coordination, fewer scramble calls, and lower readmission risk.

Outcome Highlights

Improved adherence and safety through pharmacist oversight
Earlier detection
of therapy duplications
More reliable care transitions

References

Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. J Gen Intern Med
Wuyts J, et al. (2025). Medication-related hospital readmissions: a systematic review. BMC Health Services Research. Available at: BMC Health Services Research
NCQA (2024). Medication Reconciliation Post-Discharge (MRP) Quality Measure. Available at: NCQA
Yahya R, et al. (2023). Facilitating the transfer of care from secondary to primary care: a scoping review to understand the role of pharmacists in general practice. Available at: SpringerLink
Cranor CW, Bunting BA, Christensen DB. (2003). The Asheville Project: Long-term clinical and economic outcomes of a community pharmacy diabetes care program. Available at: PubMed
Bunting BA, Cranor CW. (2002). The Asheville Project: Short-term outcomes of a community pharmacy diabetes care program. Available at: ResearchGate
American Heart Association (2023). Pharmacists’ Role in Team-Based Care for Hypertension and CVD. Available at: AHA Journals

Medication Missteps Drive 20% of Readmissions—How Your Health Closes the Gap Faster