Pharmacist Integration into Transitions of Care at a Community Hospital: Skilled Nursing Facility Discharges

Abstract

Abstract:In 2012-2013, CMH (Community Memorial Hospital) had a 10.5% 30-day readmission rate from SNFs (skilled nursing facilities). The focus of the Connections of Care Coalition was to review the medication reconciliation process and to involve pharmacists in the transition of patients to SNFs. The objective of the project was to work as an interdisciplinary team to improve the communication during transitions of care from our hospital to local SNFs by identifying key issues and initiating pharmacy practice change. This quality improvement project had a pre-post study design. Patients older than 18 years of age discharged to SNFs and/or readmitted from SNFs within 30 days were included. Baseline data was collected, specific pharmacist interventions were identified, educated on and implemented, and post-implementation data was collected. The number of interventions made and documented by pharmacists for patients being discharged from CMH to local SNFs did not significantly change during this quality improvement study. Clinically significant interventions were made on high risk medications, such as warfarin. Finally, a newly redesigned SNF workflow was implemented to include pharmacy, nursing, social work/case management to improve patient care and safety for discharges to SNFs.