By Marycon Young, Vitals contributor

When patients move between hospitals, skilled nursing facilities and home care settings, keeping medications and treatment plans aligned can become increasingly complex.

Research has shown that medication-related problems frequently occur during these transitions, making coordination among care teams especially important.

For John Foster, that coordination helped his HIV treatment continue uninterrupted during one of the most challenging periods of his care.

At 72, Foster has spent more than three decades managing HIV, a condition where consistent access to medication is critical to maintaining health and preventing complications. For more than a decade, he has received care at East Bay Advanced Care, at Sutter’s Alta Bates Summit Medical Center in Oakland, where physicians, nurses and specialty pharmacists work together to support patients with complex needs.

Each month, his medications are organized into weekly adherence trays by the specialty pharmacy team at EBAC. The customized packaging helps simplify his treatment routine and support medication adherence.

“I’ve been going to EBAC for about 11 years, and my care team has been wonderful,” Foster said. “They really know me and stay on top of everything.”

That coordination became especially important when an infection linked to a cardiac stent required hospitalization and subsequent stays at multiple skilled nursing facilities.

In Foster’s case, the challenges surfaced quickly.

Some facilities required medications to be dispensed in standard bottles rather than the adherence trays he relied on. Others were working from outdated medication lists that did not reflect his current treatment plan. In several instances, facilities were unable to supply his HIV medications on-site, creating the risk of delays or missed doses.

For people living with HIV, even brief interruptions in treatment can increase the risk of complications and drug resistance.

That’s when Dylan McNulty, a program pharmacist, and the specialty pharmacy team at EBAC stepped in to help.

“Dylan and the specialty pharmacy team at EBAC knew I was in the hospital and stepped in right away,” Foster said. “They made sure my HIV medications were appropriate, packaged based on the facility’s needs and that I got them every day.”

The team coordinated with multiple pharmacies and skilled nursing facilities to keep Foster’s medications remained aligned with his treatment plan, were packaged appropriately and arrived without delay.

“When John transitioned across different skilled nursing facilities, we knew there could be challenges, from how medications were packaged to whether therapies would be available on-site,” McNulty said. “Our role was to coordinate with facilities and pharmacies to make sure his medications were delivered in the required format and, most importantly, that his therapy wasn’t interrupted.”

Closing Gaps During Care Transitions

Foster’s experience illustrates why coordination matters during transitions between care settings. For patients with complex medication regimens, communication gaps and logistical barriers can quickly lead to treatment interruptions.

At EBAC, specialty pharmacists are embedded within the care team to help bridge those gaps.

“Transitions between care settings can create gaps in therapy if coordination isn’t in place,” McNulty said. “Our role is to stay connected and resolve barriers before they affect the patient.”

For Foster, that continuity provided peace of mind during a stressful period.

“They know the ins and outs of my treatment and what’s needed by these nursing facilities,” he said. “They made sure I didn’t miss any of my medications.”

The support extended beyond medication access. Throughout his recovery, the specialty pharmacy team remained in close communication with clinicians and care teams, monitoring his needs and helping maintain continuity as his care evolved.

A Relationship Built on Trust

Over time, Foster developed a deep appreciation for the support he received, especially during one of the most difficult periods of his care.

“I wrote Dylan a letter to thank him,” he said. “I wanted him to know how much his help meant to me.”

Today, Foster continues to receive care at EBAC and remains connected to the team that helped him navigate one of the most challenging periods of his care.

“Dylan, the specialty pharmacy team and everyone at EBAC have been great at keeping track of my medications and keeping track of me,” he said.