CTCS Exam Content Outline

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Certified Transitions of Care Specialist (CTCS)

Official Examination Content Outline

This document provides the official content outline for the Certified Transitions of Care Specialist (CTCS) examination. The exam certifies that a pharmacist possesses the specialized skills to manage the movement of patients between healthcare settings, focusing on medication reconciliation, patient education, care coordination, and the prevention of medication-related adverse events and hospital readmissions.

Examination Specifications

Name of Credential Certified Transitions of Care Specialist (CTCS)
Certification-Issuing Body The Council on Pharmacy Standards (CPS)
Designation Awarded CTCS
Target Population Pharmacists working in hospital, ambulatory, and community transition of care roles.
Examination Length 120 multiple-choice items
Administration Time 3.0 hours

Examination Content Outline

The CTCS examination is weighted according to the six domains listed below, covering the full spectrum of transitions of care practice, from patient assessment and care coordination to population health management and professional leadership.

Domain 1: Patient Assessment and Care Plan Development 20%
Domain 2: Interdisciplinary Care Coordination and Handoffs 20%
Domain 3: Discharge Planning, Counseling, and Implementation 25%
Domain 4: Post-Discharge Follow-Up, Quality, and Reimbursement 15%
Domain 5: Population Health, Risk Stratification, and Predictive Analytics 10%
Domain 6: Leadership, Professionalism, and Health Equity 10%

Domain 1: Patient Assessment and Care Plan Development (20%)

Task 1: Perform comprehensive medication reconciliation upon admission.
  • Synthesize information from multiple sources (e.g., patient interview, EHR, community pharmacy records) to create a best possible medication history (BPMH).
  • Interpret and resolve medication discrepancies between the BPMH and admission orders.
  • Assess pre-admission medication adherence patterns and identify root causes for non-adherence.
  • Intervene with the prescriber to correct clinically significant discrepancies and document all actions.
  • Evaluate the appropriateness of continuing home medications during the inpatient stay.
Task 2: Evaluate patient-specific factors to identify risks for a poor transition.
  • Analyze clinical data to identify high-risk disease states and medication regimens.
  • Assess a patient's health literacy, cognitive function, and self-management capabilities.
  • Evaluate a patient's cultural and linguistic needs to ensure care plans are equitable and understandable.
  • Apply pharmacogenomic data, when available, to personalize medication therapy.
  • Utilize standardized risk assessment tools to stratify patients at high risk for readmission.
Task 3: Incorporate social determinants of health (SDOH) and behavioral health into TOC care planning.
  • Screen for and assess SDOH barriers such as housing instability, food insecurity, and lack of transportation.
  • Incorporate behavioral health and substance use disorders into TOC planning and risk assessment.
  • Assess and document caregiver readiness and capacity to support medication adherence post-discharge.
  • Integrate resources from social work, case management, and community organizations to address identified barriers.
  • Design care plans that are realistic and achievable within the context of the patient's social and economic situation.

Domain 2: Interdisciplinary Care Coordination and Handoffs (20%)

Task 1: Optimize inpatient pharmacotherapy in collaboration with the care team.
  • Participate in interdisciplinary rounds to contribute medication-related expertise to the daily plan of care.
  • Evaluate the appropriateness of inpatient medication changes and their implications for the discharge regimen.
  • Monitor for and intervene to prevent in-hospital adverse drug events.
  • Provide evidence-based recommendations for therapy optimization throughout the hospital stay.
  • Ensure all medication-related decisions are communicated clearly to the entire care team.
Task 2: Implement seamless care coordination and handoffs.
  • Facilitate "warm handoffs" between inpatient and outpatient care providers.
  • Integrate pharmacist-led TOC activities with the work of nursing, social work, and other allied health professionals.
  • Plan transitions to long-term care, rehabilitation, or behavioral health facilities.
  • Manage transitions for patients moving to specialized settings such as skilled nursing or assisted living.
  • Ensure that a clear plan for post-discharge follow-up is in place before the patient leaves the hospital.
Task 3: Ensure pharmacist-to-pharmacist continuity across care settings.
  • Implement standardized communication protocols for transmitting critical medication information to community and outpatient pharmacists.
  • Provide clear rationale for medication changes made during the hospitalization.
  • Collaborate with outpatient pharmacists on medication access issues, such as prior authorizations or formulary changes.
  • Establish bidirectional communication channels for post-discharge problem-solving.
  • Ensure a seamless transfer of medication management responsibility to the patient's primary outpatient pharmacist.
Task 4: Utilize health information technology and interoperability standards to support safe transitions.
  • Leverage EHR functionalities to create accurate and standardized discharge medication lists.
  • Utilize health information exchanges (HIEs) and national interoperability frameworks (e.g., TEFCA) to share data securely.
  • Apply knowledge of health IT data standards (e.g., HL7, FHIR) to facilitate the exchange of clinical information.
  • Incorporate telehealth and other digital health tools into the TOC workflow for enhanced patient engagement.
  • Ensure all electronic communication and documentation complies with HIPAA and other privacy regulations.

Domain 3: Discharge Planning, Counseling, and Implementation (25%)

Task 1: Finalize the discharge medication regimen.
  • Perform the final medication reconciliation to create a single, accurate, and reconciled list of discharge medications.
  • Ensure that the discharge plan addresses all medication changes made during the hospitalization.
  • Develop management plans for high-risk medications (e.g., anticoagulants, insulin, opioids) that require specific monitoring or tapering.
  • Simplify medication regimens where possible by minimizing frequency, consolidating doses, and eliminating unnecessary drugs.
  • Verify that all discharge prescriptions are accurate, complete, and sent to the correct pharmacy.
Task 2: Deliver effective, patient-centered discharge counseling.
  • Develop patient-friendly educational materials (e.g., Personal Medication List, Medication Action Plan) in plain language.
  • Employ the teach-back method to confirm patient and caregiver understanding of the discharge plan.
  • Tailor counseling strategies to accommodate for limited health literacy and cultural or linguistic diversity.
  • Provide clear instructions on what to do if a dose is missed or an adverse effect occurs.
  • Ensure the patient knows who to contact with medication-related questions after discharge.
Task 3: Prepare and support caregivers in post-discharge medication management.
  • Assess the caregiver's ability and willingness to assist with medication management.
  • Provide specific training to caregivers on administering complex medications (e.g., injections, inhalers).
  • Educate caregivers on how to use adherence tools such as pill boxes, med synchronization, and reminder apps.
  • Involve caregivers in the teach-back process to confirm their understanding of the medication plan.
  • Provide caregivers with resources and contact information for post-discharge support.
Task 4: Implement strategies to ensure medication access and adherence.
  • Intervene before discharge to resolve barriers to medication access, such as affordability and transportation.
  • Coordinate with on-site services (e.g., "Meds-to-Beds" programs) to ensure patients have medications in hand before leaving.
  • Connect patients with manufacturer assistance programs, co-pay cards, or other financial resources.
  • Integrate technology-enabled adherence support (e.g., smart pill bottles, mobile apps) into the discharge plan.
  • Arrange for the first post-discharge fill and any necessary refills to be ready at the patient's pharmacy.

Domain 4: Post-Discharge Follow-Up, Quality, and Reimbursement (15%)

Task 1: Manage post-discharge follow-up and problem-solving.
  • Implement a structured process for post-discharge follow-up (e.g., phone calls, home visits, telehealth) to assess patient status.
  • Identify and resolve medication-related problems that arise after discharge, coordinating with outpatient providers as needed.
  • Provide ongoing support and reinforcement to patients and caregivers during the vulnerable post-discharge period.
  • Reconcile medications again at the first post-discharge visit or encounter.
  • Report TOC-related medication safety events through institutional and national reporting systems.
Task 2: Evaluate the impact of TOC services on quality metrics.
  • Analyze key performance indicators, such as 30-day readmission rates, medication-related hospitalizations, and patient satisfaction.
  • Align TOC activities with institutional and national quality metrics (e.g., HEDIS, CMS Star Ratings).
  • Implement a continuous quality improvement (CQI) process to refine the TOC program.
  • Ensure that TOC processes are aligned with Joint Commission standards and other accreditation requirements.
  • Prepare and present reports on TOC outcomes to pharmacy and hospital leadership.
Task 3: Apply relevant regulatory and value-based reimbursement models.
  • Ensure that all documentation and communication practices comply with legal and regulatory requirements (e.g., HIPAA, CMS mandates).
  • Apply knowledge of relevant billing codes (e.g., Transitional Care Management codes) to support the sustainability of TOC services.
  • Analyze and report TOC-related performance under value-based reimbursement models (e.g., bundled payments, ACOs).
  • Demonstrate the financial impact and return on investment of pharmacist-led TOC services.
  • Align the TOC program with the goals of the CMS Hospital Readmissions Reduction Program (HRRP).
Task 4: Leverage telehealth and remote patient monitoring (RPM) to improve post-discharge care.
  • Integrate virtual visits into the post-discharge follow-up process to improve patient access.
  • Utilize remote patient monitoring (RPM) devices for medication adherence and vital sign tracking.
  • Use secure messaging platforms to provide ongoing support and answer patient questions.
  • Evaluate the effectiveness of telehealth interventions on patient outcomes and resource utilization.
  • Ensure that all telehealth activities are conducted in a compliant and secure manner.

Domain 5: Population Health, Risk Stratification, and Predictive Analytics (10%)

Task 1: Apply population health principles to transitions of care.
  • Analyze population-level data to identify trends in readmissions and medication-related problems.
  • Design and implement TOC programs that target specific high-risk populations.
  • Develop standardized clinical pathways for common disease states to improve the consistency of care.
  • Collaborate with public health organizations and community partners to address population-level health needs.
  • Measure the impact of TOC interventions on the health outcomes of the entire patient population.
Task 2: Utilize predictive modeling and risk stratification to target interventions.
  • Apply predictive analytics and machine learning models to identify patients at the highest risk of readmission.
  • Stratify populations based on risk factors such as polypharmacy, high-cost medications, and high healthcare utilization.
  • Integrate data from multiple sources (e.g., clinical, claims, social) to create comprehensive risk profiles.
  • Develop risk-based workflows that allocate pharmacist resources to the patients who will benefit most.
  • Continuously evaluate and refine predictive models to improve their accuracy and effectiveness.
Task 3: Align TOC activities with value-based care contracts.
  • Analyze the requirements of various value-based care models (e.g., ACOs, bundled payments, shared savings).
  • Design TOC services that directly support the quality and cost-containment goals of these contracts.
  • Develop metrics and reporting systems to demonstrate the value of TOC services to payers and health system leaders.
  • Collaborate with finance and contracting departments to ensure that TOC services are properly valued and supported.
  • Advocate for the inclusion of pharmacist-led TOC services in future value-based care agreements.

Domain 6: Leadership, Professionalism, and Health Equity (10%)

Task 1: Lead interdisciplinary transitions of care teams.
  • Facilitate team meetings and care conferences to ensure a coordinated approach to patient care.
  • Develop and implement standardized workflows and communication protocols for the TOC team.
  • Provide mentorship and coaching to other members of the healthcare team on TOC best practices.
  • Resolve conflicts and build consensus among team members with different professional backgrounds.
  • Advocate for the resources and support needed for the TOC team to be successful.
Task 2: Address health disparities and promote health equity in transitions of care.
  • Analyze data to identify disparities in readmission rates and other outcomes among different patient populations.
  • Design culturally and linguistically appropriate interventions to meet the needs of diverse patient groups.
  • Advocate for policies and programs that address the root causes of health inequities.
  • Promote institutional accountability for reducing disparities in readmissions and adverse drug events.
  • Partner with community-based organizations to build trust and improve access to care for underserved populations.
Task 3: Manage the training and professional development of TOC staff.
  • Develop a comprehensive training and orientation program for new staff members involved in TOC.
  • Lead staff training and competency validation for all TOC processes and procedures.
  • Implement a competency assessment program to ensure that all staff have the necessary skills and knowledge.
  • Provide ongoing education and professional development opportunities for the TOC team.
  • Foster a culture of continuous learning and quality improvement.

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