Evaluating the effects of a multidisciplinary transition care management program on hospital readmissions

Abstract

Purpose To measure the effect of a pharmacist-initiated transitions of care (TOC) program on rates of 30-day all-cause readmissions and primary care follow-up. Methods A retrospective cohort study was conducted to evaluate a pharmacist-initiated TOC program for patients discharged from hospitals of a large health system from September 2015 through July 2016. Discharged patients of 13 primary care physicians (the intervention cohort) received TOC program services, and discharged patients seen by 12 other primary care physicians (the control cohort) received usual care. Patients in both cohorts were followed for 90 days. The primary outcome was 30-day all-cause readmissions, and secondary outcomes were 14-day primary care visits, TOC pharmacist identification and resolution of medication therapy problems (MTPs), and transition care management (TCM) billing. Multivariable modeling was performed to test the associations of patient receipt of TOC services with 30-day readmissions and 14-day primary care visits, with controlling for patient demographics and baseline healthcare utilization. Results A total of 492 patients received the TOC intervention, and 379 were followed in the usual care cohort. Among intervention patients, 960 MTPs were identified, and 85.7% of identified MTPs were resolved. Moreover, 9% of intervention cohort patients were readmitted within 30 days, compared to 15% of control cohort patients, and this effect was significant in the multivariable model (odds ratio, 1.82; 95% confidence interval, 1.15-2.89; P = 0.0108). Rates of primary care visits did not differ significantly between the groups; 65% of intervention group visits were billed using TCM codes. Conclusion A pharmacist-initiated TOC program was effective in reducing 30-day all-cause readmissions.

Clinical Pharmacist Transition of Care Model Improves Hospital System Practice by Reducing Readmissions

“…The cutoff value of 10 home medications was chosen based on a review of the current literature, which found that 43% of hospitalized patients have $10 home medications. 10 In addition, a cut-off of 10 home medications provided a standardized metric to identify potential patients. The team identified polypharmacy patients with $10 home medications through an EHR-based daily report of new patients admitted to the medicine service.…”

Implementing Transitions of Care Services in a Primary Care Clinic: Role of the Pharmacist

“…4 Pharmacist involvement is advantageous during the transition from inpatient to outpatient setting by improving patient safety and adherence, avoid costs associated with medication errors, and reducing readmissions for high-risk patient populations which has been demonstrated in multiple studies. [5][6][7][8][9][10][11][12] The pharmacist's role in TOC in a primary care setting and its potential impact on health care utilization rates is less studied than upon discharge from the hospital and requires further investigation.…”

Incorporating Pharmacists into the Primary Care Team

“…As an adjunct to the above described benefits, Synder et al have recently shown that a pharmacist-initiated transitions of care program decreased the odds of 30-day all-cause readmissions compared to usual care. 3 Of additional note, a 2018 study demonstrated an ambulatory care pharmacy-based transitions-of-care program yielded an estimated cost saving of nearly $1.8 million for the managed care plan. 4 This information clearly shows the added value of pharmacists in this area of patient care.…”