Implementation Science Workshop: Primary Care-Based Multidisciplinary Readmission Prevention Program

Post-Hospital Discharge Care: A Retrospective Cohort Study Exploring the Value of Pharmacist-Enhanced Care and Describing Medication-Related Problems

“…Furthermore, most of these studies have utilized pharmacy services for specific high-risk populations versus all discharged patients [19,20,22,23,35,37]. This study adds to the existing but limited body of literature emphasizing a reduction in readmissions, albeit non-significant, following face-to-face pharmacist hospital follow-up visits with a multidisciplinary team in a patient-centered medical home.…”

“…complete list of medication information-should not be performed alone, but combined with counseling and a clinical medication review [18,22,23,35,36].…”

“…Another potential reason for the low readmission rate observed is that only patients who attended a hospital follow-up appointment within 30 days were included in the study, and research indicates that patients are less likely to be readmitted if they attend a primary care followup appointment after discharge [34]. Our institution's internal readmission risk stratification considers patients with 2 past hospitalizations as moderate-risk and those with 3 or more as high-risk [23,35]. In 2013, moderate and highrisk patients accounted for approximately 84% of all UNC rehospitalizations (40% for moderate-risk and 44% for high-risk).…”

“…In 2013, moderate and highrisk patients accounted for approximately 84% of all UNC rehospitalizations (40% for moderate-risk and 44% for high-risk). Studies evaluating the impact of similar face-toface pharmacist interventions at UNC in moderate to highrisk patients have demonstrated significant and pronounced reductions in utilization [18,23,35].…”

“…The patients had either more than 3 hospitalizations in the past 5 years; 8 or more scheduled medications anticipated at discharge; or a reason for admission of heart failure, chronic obstructive pulmonary disease (COPD), stroke, unstable angina, or non-ST segment myocardial infarction. Furthermore, our institution's internal readmission risk stratification considers patients with 3 or more hospital admissions in the last year, or at least 3 chronic conditions and at least 10 medications, as high-risk; 2 or more hospital admissions in the last year, or at least 2 chronic conditions with no regard to medications, as moderate-risk; and all other patients as low-risk [23]. Studies evaluating the impact of similar face-to-face pharmacist interventions at UNC in moderate to high-risk patients have demonstrated significant reductions in utilization [18,23].…”