Implementation and Effect of a Pharmacist-to-Pharmacist Transitions of Care Initiative on Ambulatory Care Sensitive Conditions

Abstract

BACKGROUND: One of the most vulnerable times in a patient's encounter with a health care system is during transitions of care (TOC), defined by the Joint Commission as the movement of a patient from one health care provider or setting to another. The use of a clinical pharmacist as a member of the care transitions team has received focused attention and shown improved benefit. OBJECTIVE: To determine the effect of a large-scale pharmacist-to-pharmacist TOC model where inpatient clinical pharmacists identify patients during a hospital stay, provide evidence-based care and education, and then coordinate follow-up with an outpatient clinical pharmacist who provided comprehensive medication management (CMM) under a scope of practice.METHODS: This was a multisite, single health care system, quasi-experimental, matched interrupted time series design study conducted at an integrated Veterans Affairs (VA) health care system. Patients admitted with a primary or secondary diagnosis of diabetes, hypertension, chronic obstructive pulmonary disease (COPD) and heart failure (HF) were included for enrollment. Clinical pharmacists rounding on inpatient medical teams provided evidence-based recommendations to optimize medications while coordinating follow-up by an outpatient clinical pharmacy specialist within 10 days of discharge for CMM. The primary endpoint of this study was to determine the effect on the composite all-cause 30-day acute care utilization rate (emergency department [ED] visit or hospital readmission) for patients discharged with a primary or secondary diagnosis of diabetes, hypertension, COPD, and HF compared with a comparator group of patients with similar discharge diagnosis before implementation of the TOC program. RESULTS: 484 patients (242 in each group, with 366 heart failure, 66 COPD, 10 hypertension, and 42 diabetes) were included for analysis. For the primary outcome of composite 30-day, all-cause acute care utilization rates, no statistically significant difference was identified, with 26.9% of patients in the intervention group and 28.9% in the historical group readmitted or seen in the ED within 30 days of discharge (P = 0.6852). Outcomes for the HF index acute care utilization rate (i.e., admission for the same disease state discharged with), including 30-day index readmissions (P = 0.0014), 30-day index ED visits (P = 0.0047), and 90-day index readmissions for HF (P < 0.0001) were significantly reduced. CONCLUSIONS: Our study is one of the first to identify at-risk patients using rounding clinical pharmacists in the acute care arena and coordination of care systematically with a clinical pharmacy specialist practicing under a scope of practice targeted for CMM. Although the overall primary endpoint was not met, a reduction in acute care utilization rates for HF at 30 and 90 days can be achieved.

Impact of a Pharmaceutical Care Program at Discharge on Patients at High Risk of Readmission According to the Hospital Score

“…As is evident from the literature, 17,20,25 the study results highlight the relationship between polypharmacy and the risk of 30-day readmission. Therefore, PIs that achieve a reduction in polypharmacy and contribute to improving treatment efficacy and safety will potentially affect patient health outcomes.…”

“…In the scientific literature, an experience of coordination between pharmacists at different levels of care shows that because of their position in the health system, pharmacists can act as liaison figures with other professionals, facilitating the exchange of information, the resolution of discrepancies detected, or clarifying doubts that the patient may have. 20…”

Collaboration between pharmacists in community pharmacy and ambulatory clinic settings: Current state and future directions

“…Table 1 summarizes evidence showing methods for improved collaboration that are sustainable and financially viable 12,15,30,31,38–45 . It is important to acknowledge that the growth and development of pharmacist‐to‐pharmacist collaborative practices in these early stages contribute to the heterogeneity of outcomes.…”

“…37 Table 1 summarizes evidence showing methods for improved collaboration that are sustainable and financially viable. 12,15,30,31,[38][39][40][41][42][43][44][45] It is important to acknowledge that the growth and development of pharmacist-to-pharmacist collaborative practices in these early stages contribute to the heterogeneity of outcomes. Clinicians and teams of collaborators can look to guidance documents/tools for proposed quality metrics to guide future design for alignment around key outcomes.…”

Evaluation of pharmacist impact on a multidisciplinary transitions of care service in Bundled Payments for Care Improvement Advanced model patients

“…Indeed, data support pharmacist-led transitional care clinics as able to reduce hospital revisits. [7][8][9] A key study evaluated 90-day readmissions among BPCI-A patients before and after implementation of a pharmacist-led transitional care clinic where clinical pharmacists recommended additional drug therapy, facilitated preventative care, and discontinued duplicate medications. This study demonstrated an 8.34% reduction in 90-day hospital readmissions among BPCI-A patients.…”