The effect of a pharmacist-led multidisciplinary transitions-of-care pilot for patients at high risk of readmission.

OBJECTIVES: To evaluate the feasibility and effect of a pharmacist-led transitions-of-care (TOC) pilot targeted to patients at high risk of readmission on process measures, hospital readmissions, and emergency department (ED) visits.

SETTING: Academic medical center in Colorado.

PRACTICE DESCRIPTION: Pharmacists enrolled patients identified as high risk for readmission in a TOC pilot from July 2014 to July 2015. The pilot included medication reconciliation, medication counseling, case management or social work evaluation, a postdischarge telephone call, and an expedited primary care follow-up appointment.

PRACTICE INNOVATION: Implementation and evaluation of the pharmacist-led TOC pilot program with risk score embedded into the electronic health record.

EVALUATION: Comparison of TOC-related process measures and clinical outcomes between pilot patients and randomly matched control patients included readmissions or ED visits at 30 and 90 days.

RESULTS: We enrolled 34 pilot patients and randomly matched them to 34 control patients. The intervention took an average of 57.1 minutes for pharmacists to deliver. More pilot patients had a case management or social work note compared with control patients (88% vs. 59%; P = 0.006 [statistically significant]). Readmission rates in pilot versus nonpilot patients, respectively, were 18% versus 24% (P = 0.547) at 30 days and 27% versus 39% (P = 0.296) at 90 days. The composite outcome of a readmission or ED visit in pilot versus nonpilot patients was 24% versus 30% (P = 0.580) at 30 days and 36% versus 49% (P = 0.319) at 90 days.

CONCLUSION: A pharmacist-led TOC pilot demonstrates potential for reducing hospital readmissions. The intervention was time intensive and led to creation of a TOC pharmacist role to implement medication-related transitional care.