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

IntroductionPharmacists in primary care clinics improve medication adherence and reduce medication errors but these require further investigation to determine its potential impact on health care readmission rates. Methods: This review assessed the addition of a clinical pharmacist to the primary care provider's transitions of care appointment. The primary outcome of this review was the change in acute health care encounters (hospital readmissions and/or Emergency Department visits) in the 6-month period before to the 6 months following initial clinical pharmacist intervention. Each patient served as their own control. Secondary outcomes included the number and types of pharmacist interventions, percentage of pharmacist recommendations accepted, number and categories of drug-related problems (DRPs), nonadherence reasons, 30-day hospital readmission rate, 30-day Emergency Department (ED) rate, time to first hospital readmission, time to first ED readmission, and preventable readmission rate. Results: The total number of combined acute health care encounters in 6 months decreased by 15% from 280 at baseline to 238 after pharmacist intervention (P = .087) for the 206 patients included in the final analysis. The 30-day hospital readmission rate was 9.7% and the median time between first hospital readmission was 54.5 days (IQR 63.5). We identified a total number of 310 DRPs with a mean of 1.5 DRPs (SD 1.3) identified per patient. The providers accepted 88% of the pharmacists' recommendations. Conclusions: Clinical pharmacists embedded in a primary care setting demonstrated improved patient care during transitions of care by identifying and resolving drug-related problems, with a trend in decreasing acute health care utilization.

Effectiveness of pharmacist-led medication reconciliation on medication errors at hospital discharge and healthcare utilization in the next 30 days: a pragmatic clinical trial

Transitions of care often lead to medication errors and unnecessary healthcare utilization. Medication reconciliation has been repeatedly shown to reduce this risk. However, the great majority of evidence is limited to the provision of medication reconciliation within clinical trials and countries with well-established clinical pharmacy. Thus, this pragmatic, prospective, controlled trial evaluated the effectiveness of routine pharmacist-led medication reconciliation compared to standard care on medication errors and unplanned healthcare utilization in adult general medical patients hospitalized in a teaching hospital in Slovenia. All patients hospitalized in a ward where medication reconciliation was integrated into routine clinical practice were included in the intervention group and received admission and discharge medication reconciliation, coupled with patient counselling. The control group consisted of randomly selected patients from the remaining medical wards. The primary study outcome was unplanned healthcare utilization within 30 days of discharge, and the secondary outcomes were clinically important medication errors at hospital discharge and serious unplanned healthcare utilization within 30 days of discharge. Overall, 414 patients (53.4% male, median 71 years) were included-225 in the intervention group and 189 in the control group. In the intervention group, the number of patients with clinically important medication errors at discharge was significantly lower (intervention vs control group: 9.3% vs 61.9%). Multiple logistic regression revealed that medication reconciliation reduced the likelihood of a clinically important medication error by 20-fold, while a higher number of medications on admission was associated with an increased likelihood. However, no significant differences were noted in any and serious unplanned healthcare utilization (intervention vs control group: 33.9% vs 27.8% and 20.3% vs 14.6%, respectively). The likelihood of serious healthcare utilization increased with the age of the patient, the number of medications on admission and being hospitalized for an acute medical condition. Our pragmatic trial confirmed that medication reconciliation, even when performed as part of routine clinical practice, led to a substantial reduction in the risk of clinically important medication errors at hospital discharge but not to a reduction in healthcare utilization. Medication reconciliation is a fundamental, albeit not sufficient, element to ensure patient safety after hospital discharge. Clinical Trial Registration: https://clinicaltrials.gov/search?id=NCT06207500, identifier NCT06207500.

The FlaQuM-Quickscan: A starting point to include primary care professionals' perspectives in the evaluation of hospital quality priorities

INTRODUCTION

Today, primary care professionals' (PCPs) perspectives on hospital quality are unknown when evaluating hospital quality priorities. The aims of the present study were to identify key healthcare quality attributes from PCPs' perspective, to validate an instrument that measures PCPs' experiences of healthcare quality multidimensionally and to define hospital quality priorities based on PCPs' experiences.

MATERIAL AND METHODS

Focus groups with PCPs were conducted to identify quality attributes through a qualitative in-depth analysis. A multicentre study of 18 hospitals was used to quantitatively assess construct, discriminant and criterion validity of the FlaQuM-Quickscan, an instrument that measures 'Healthcare quality for patients and kin' (part 1) and 'Healthcare quality for professionals' (part 2). To set quality priorities, scores on quality domains were analyzed descriptively and between-hospital variation was examined by evaluating differences in hospitals' mean scores on the quality domains using one-way Analysis of Variance (ANOVA).

RESULTS

Identified key attributes largely corresponded with Lachman's multidimensional quality model. Including 'Communication' as a new quality domain was recommended. The FlaQuM-Quickscan was completed by 550 PCPs. Confirmatory factor analyses showed reasonable to good fit, except for the Root Mean Square Error of Approximation (RMSEA) in part 2. The 'Equity' domain scored the highest in parts 1 and 2. Domains 'Kin-centred care' and 'Accessibility and timeliness' scored the lowest in part 1 and 'Resilience' and 'Partnership and co-production' in part 2. Significant variation in hospitals' mean scores was observed for eleven domains in part 1 and sixteen domains in part 2.

CONCLUSIONS

The results gained a better understanding of PCPs' perspective on quality. The FlaQuM-Quickscan is a valid instrument to measure PCPs' experiences of hospital quality. Identified priorities indicate that hospital management should focus on multifaceted quality strategies, including technical domains, person-and kin-centredness, core values and catalysts.

The impact of hospital-based post-discharge pharmacist medication review on patient clinical outcomes: A systematic review

Background

Clinical pharmacists have been shown to identify and resolve medication related problems post-discharge, however the impact on patient clinical outcomes is unclear.

Aims

To undertake a systematic review to identify, critically appraise and present the evidence on post-discharge hospital clinics that provide clinical pharmacist medication review; report the patient clinical outcomes measured; and describe the activities of the clinical pharmacist.

Methods

Published studies evaluating a patient clinical outcome following a post-discharge hospital clinic pharmacy service were included. All studies needed a comparative design (intervention vs control or comparator). Pubmed, Embase, CINAHL, PsycnINFO, Web of Science, IPA and APAIS-Health databases were searched to identify studies. The type of clinic and the clinical pharmacist activities were linked to patient clinical outcomes.

Results

Fifty-seven studies were included in the final analysis, 14 randomised controlled trials and 43 non-randomised studies. Three key clinic types were identified: post-discharge pharmacist review alone, inpatient care plus post-discharge review and post-discharge collaborative clinics. The three main outcome metrics identified were hospital readmission and/or representation, adverse events and improved disease state metrics. There was often a mix of these outcomes reported as primary and secondary outcomes. High heterogeneity of interventions and clinical pharmacist activities reported meant it was difficult to link clinical pharmacist activities with the outcomes reported.

Conclusions

A post-discharge clinic pharmacist may improve patient clinical outcomes such as hospital readmission and representation rates. Future research needs to provide a clearer description of the clinical pharmacist activities provided in both arms of comparative studies.

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

PURPOSE

A primary cause of hospital readmission is medication-related problems (MRPs). Polypharmacy patients taking multiple medications concurrently experience an increased likelihood of MRPs and high occurrence of readmissions to the hospital within 30 days. This study assessed the ability of a pharmacist-led transition of care program to decrease readmissions in polypharmacy patients by evaluating and rectifying MRPs.

METHODS

Over 16 months, patients admitted onto the medicine ward service with ≥10 home medications ( n = 536) received medication management interventions from a clinical pharmacist including admission interview, medication reconciliation and consultation, and postdischarge phone follow-up. Admitted patients taking fewer than 10 home medications during the same time served as the control group and received routine standard of care ( n = 2317).

RESULTS

The polypharmacy group who received the pharmacist-led intervention had a statistically significantly lower 30-day readmission rate (8.8%) compared with patients in the control group (12.4%; X 2 = 5.63, p = .01). Patients receiving pharmacist intervention were 33% less likely to be readmitted within 30 days of discharge compared with the control group (odds ratio = 0.67, 95% CI = 0.49-0.94). All patients had at least one medication-related discrepancy.

CONCLUSION

This pharmacy-led transition of care program can effectively reduce readmission rates through resolution of medication-related problems.

Uptake of pharmacist recommendations by patients after discharge: Implementation study of a patient-centered medicines review service

BACKGROUND

Polypharmacy and potentially inappropriate medicine use is common in older people, resulting in harm increased by lack of patient-centred care. Hospital clinical pharmacy services may reduce such harm, particularly prevalent at transitions of care. An implementation program to achieve such services can be a complex long-term process.

OBJECTIVES

To describe an implementation program and discuss its application in the development of a patient-centred discharge medicine review service; to assess service impact on older patients and their caregivers.

METHOD

An implementation program was begun in 2006. To assess program effectiveness, 100 patients were recruited for follow-up after discharge from a private hospital between July 2019 and March 2020. There were no exclusion criteria other than age less than 65 years. Medicine review and education were provided for each patient/caregiver by a clinical pharmacist, including recommendations for future management, written in lay language. Patients were asked to consult their general practitioner to discuss those recommendations important to them. Patients were followed-up after discharge.

RESULTS

Of 368 recommendations made, 351 (95%) were actioned by patients, resulting in 284 (77% of those actioned) being implemented, and 206 regularly taken medicines (19.7 % of all regular medicines) deprescribed.

CONCLUSION

Implementation of a patient-centred medicine review discharge service resulted in patient-reported reduction in potentially inappropriate medicine use and hospital funding of this service. This study was registered retrospectively on 12^th July 2022 with the ISRCTN registry, ISRCTN21156862, https://www.isrctn.com/ISRCTN21156862 .

Effect of pharmacy-led interventions during care transitions on patient hospital readmission: A systematic review

BACKGROUND

The Centers for Medicare and Medicaid (CMS) established the Hospital Readmissions Reduction Program (HRRP) to reduce reimbursement payments to hospitals with excessive patient readmissions. Because of this program, hospitals have developed transitions of care (TOC) programs to improve patient outcomes.

OBJECTIVES

To identify and uniformly summarize the impact of pharmacy-led TOC interventions on 30-day readmission rates since the implementation of CMS HRRP.

METHODS

This study followed an a-priori protocol that was registered to International Prospective Register of Systematic Reviews. A systematic search was conducted using PubMed, EMBASE, International Pharmaceutical Abstracts, and CINAHL from January 1, 2013 through January 14, 2022. Studies were included if they met the following criteria: pharmacy-led intervention, 30-day readmission outcomes, patients at least 18 years old, original research performed in the United States, and English language only articles. Descriptive statistics were used to summarize study characteristics, outcomes, and elements of the study interventions.

RESULTS

A total of 1964 abstracts were screened with 123 studies being included in the review. A total of 110 (89.4%) studies showed a decrease in readmission rates. The largest decrease in readmission rates was 44.5% (range 0.2%-44.5%, median = 7.4%) and the most common pharmacy-led intervention was patient counseling (n = 119, 96.7%) followed by medication reconciliation (n = 111, 90.2%). High-risk patient populations were commonly targeted with 52 studies (42.3%) focusing on CMS HRRP related diagnoses.

CONCLUSION

Most pharmacist-led TOC interventions contributed to lower rates of 30-day readmission. Future studies should investigate the types of interventions that most significantly impact readmission rates.

A new perspective: Practice-enhancing publications about the ambulatory care medication-use process in 2020

DISCLAIMER

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

This article identifies, prioritizes, and summarizes published literature on the ambulatory care medication-use process (ACMUP) from calendar year 2020 that can impact ambulatory pharmacy practice.

SUMMARY

The medication-use process is the foundational system that provides the framework for safe medication utilization within the healthcare environment and was reimagined to focus on new innovations and advancements in ambulatory pharmacy practice. The ACMUP is defined in this article as having the following components: transitions of care, prescribing and collaborative practice, accessing care, adherence, and monitoring and quality. Articles evaluating at least one step of the ACMUP were assessed for their usefulness toward practice improvement. A PubMed search covering calendar year 2020 was conducted in January 2021 using targeted Medical Subject Headings (MeSH) keywords and the table of contents of selected pharmacy journals, providing a total of 9,433 articles. A thorough review identified 65 potentially practice-enhancing articles: 14 for transitions of care, 19 for prescribing and collaborative practice, 10 for adherence, 6 for accessing care, and 16 for monitoring and quality. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why each article is important. The other articles are listed for further review and evaluation.

CONCLUSION

It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article is the first to define and evaluate the currently published literature pertinent to the ACMUP. As healthcare continues to advance and care shifts to ambulatory settings, the ACMUP will continue to be a crucial process to evaluate.