Implementing a pharmacy resident run transition of care service for heart failure patients: Effect on readmission rates

Pharmacist-Led Discharge Transitions of Care Interventions for Pediatric Patients: A Narrative Review

Transitions of care (TOC) before, during, and after hospital discharge are an opportune setting to optimize medication management. The quality standards for pediatric care transitions, however, are lacking, leading to reduced health outcomes in children. This narrative review characterizes the pediatric populations that would benefit from focused, TOC interventions. Different types of medication-focused TOC interventions during hospital discharge are described, including medication reconciliation, education, access, and adherence tools. Various TOC intervention delivery models following hospital discharge are also reviewed. The goal of this narrative review is to help pediatric pharmacists and pharmacy leaders better understand TOC interventions and integrate them into the hospital discharge process for children and their caregivers.

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.

Impact of a pharmacist-inclusive post-discharge clinic on outcomes in heart failure patients with reduced ejection fraction: Rates of hospital readmission, emergency department visits, or death

Introduction

Heart failure hospitalization is a hallmark of disease progression associated with increased morbidity and mortality. Benefits of multidisciplinary clinics have been established in the care of heart failure patients and can be particularly impactful post-hospital discharge.

Objective

This study aimed to investigate the impact of a clinical pharmacist-integrated model of care within a Heart Failure Bridge Clinic (HFBC) at a large tertiary care referral center.

Methods

In this single-center retrospective study, patients with left ventricular ejection fraction (LVEF) ≤40% discharged from Mission Hospital (Asheville, North Carolina) between August 2018 and July 2019 were screened. Patients in the HFBC arm had a clinic visit inclusive of a clinical pharmacist within 30 days of hospital discharge and were compared with a control group of patients with a usual care provider clinic visit. The HFBC provided clinical assessment, detailed heart failure education, and medication reconciliation and adjustment with an emphasis on optimization of Guideline Directed Medical Therapy (GDMT). Patients were followed for 90 days for the primary end point of hospitalization, emergency department (ED) visit, or death.

Results

A total of 1463 patients (HFBC, n = 307; control, n = 1156) comprised our final cohort. After accounting for baseline variables, 90-day cumulative probability of hospitalization, ED visit, or death favored HFBC patients (26% vs 32%, P = .0275). Comprehensive review of medications prior to and after HFBC appointment demonstrated significant alterations to therapies (30% GDMT addition, 27% GDMT titration, 7.2% discontinuation of medications associated with worsening heart failure, and 28% loop diuretic adjustment).

Conclusion

Clinical pharmacist-integrated HFBC allows for focused medication review and optimization and is associated with a 19% relative risk reduction in hospitalization, ED visit, or death at 90 days.

Implementation of a pharmacist-led transitional care clinic

PURPOSE

To describe a pharmacist-led transitional care clinic (TCC) for high-risk patients who were recently hospitalized or seen in the emergency department (ED).

SUMMARY

The Memphis Veterans Affairs Medical Center (VAMC) established a pharmacist-led face-to-face and telephone follow-up TCC to improve posthospitalization follow-up care through medication optimization and disease state management, particularly for veterans with high-risk disease states such as chronic obstructive pulmonary disease (COPD) and heart failure (HF). The clinic's clinical pharmacy specialists (CPSs) ordered diagnostic and laboratory tests, performed physical assessments, and consulted other providers and specialty services in addition to performing medication reconciliation, compliance assessment, and evaluation of adverse drug events. TCC patients were typically seen within 2 weeks of discharge and subsequently referred back to their primary care provider or a specialty care provider for continued management. A retrospective review of 2016 TCC data found that 7.8% of patients seen in the TCC were readmitted within 30 days of discharge; readmission rates for COPD and HF were reduced to 13% and 10%, respectively, compared to hospital-wide readmission rates of 17% and 24%. A separate observational analysis found that 30-day readmissions for COPD and HF were reduced in TCC patients, with pharmacists documenting an average of 6.2 interventions and 3.3 medication-related problems per patient. To reduce clinic appointment no-shows, the CPSs worked with inpatient providers and schedulers to emphasize to patients the importance of clinic attendance; also, TCC services were expanded to include telehealth appointments to increase access for rural and/or homebound patients.

CONCLUSION

A pharmacist-led TCC effectively reduced readmissions and prevented medication-related problems for high-risk patients who were hospitalized or seen in the ED.

Pharmacist Transition-of-Care Services Improve Patient Satisfaction and Decrease Hospital Readmissions

BACKGROUND

Pharmacists ability to directly impact patient satisfaction through increases in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys utilizing transitions-of-care (TOC) services is unclear.

METHODS

Retrospective analysis of TOC patients from 07/01/2018 to 03/31/2019 was conducted. Intervention (INV) patients received pharmacist medication reconciliation and education prior to discharge and post-discharge telephone follow-up. All other patients served as control group (CON). Primary outcome: Evaluate impact of TOC services on HCAHPS scores for "Communication about Medicines" and "Care Transitions." Secondary outcomes: 30-day readmissions, quantification of prevented potential safety events, assessment of discharge prescriptions sent to the academic medical center outpatient pharmacy (MOP) for TOC patients.

RESULTS

Of 1,728 patients screened, 414 patients met inclusion criteria (INV = 414, CON = 1314). A significant improvement (14.7%; p = <0.0001) in overall medication-related HCAHPS results was seen when comparing pre- vs post-implementation of the TOC service. Statistically significant increases for individual questions "staff told you what the medicine was for" (14.2%; p = 0.018), "staff describe possible effects" (21.2%; p = 0.004), and "understood the purpose of taking medications" (11.4%; p = 0.035) were observed. A non-significant decrease in 30-day readmission rates for the groups was observed (CON 16.4%, INV 13.3%; p = 0.133); however, an unplanned subgroup analysis evaluating impact of discharge phone calls on 30-day readmission rates revealed a significant reduction of 17.3% to 12.4% (p = 0.007). One hundred forty-three medication safety event(s) were potentially prevented by the TOC pharmacist. Lastly, 562 prescriptions were captured at the MOP as a result of the TOC initiative.

CONCLUSIONS

Pharmacy-based TOC models can improve patient satisfaction, prevent hospital readmissions, and generate revenue.

Impact of Heart Failure Transitions of Care Program: A Prospective Study of Heart Failure Education and Patient Satisfaction

Purpose: The purpose of the study is to evaluate the impact of heart failure medication education on 30-day all-cause readmission rates and patient-reported satisfaction scores. Methods: This single-center pilot study was conducted at a 396-bed tertiary-care hospital in the Midwest from September 2017 to December 2018. For research purposes, patients were divided into 2 groups. The control group was looked at retrospectively and included patients who received education by the nurse educator. The intervention group was reviewed proactively and included patients who received education by a pharmacy student. The purpose of the study was to compare readmission rates among patients who received medication education from pharmacy students with those who received the same education by the heart failure nurse educator. The primary outcome was 30-day all-cause readmission rate among those with a diagnosis of heart failure. The secondary endpoints included patient satisfaction scores by phone survey. The patient satisfaction phone survey was conducted by a single pharmacist 1 week after patient education was provided. Results: For the primary endpoint, there were 222 patients in the treatment group compared with the control group of 941 patients. The treatment group resulted in 30 (13.5%) of the 222 patients being readmitted within 30 days compared with the control group where 186 (19.6%) of the 941 were readmitted (P = .0395). The risk reduction in odds ratio and relative risk of readmission was 0.63 (confidence interval [CI] = 0.42-0.96) for the treatment group and 0.68 (CI = 0.48-0.98) for the control group. For the secondary endpoint, 56 patients were called 1 week after discharge, and there was no significant difference in overall patient satisfaction between groups. Conclusion: This study demonstrated that heart failure medication education provided by the pharmacist or pharmacy student resulted in improved patient outcomes and ultimately a reduction in 30-day all-cause readmission rates.

Hospitalization and post-discharge care in South Africa: A critical event in the continuum of care

OBJECTIVES

The purpose of this prospective cohort study is to characterize the event of acute hospitalization for people living with and without HIV and describe its impact on the care continuum. This study describes care-seeking behavior prior to an index hospitalization, inpatient HIV testing and diagnosis, discharge instructions, and follow-up care for patients for patients being discharged from a single hospital in South Africa.

METHODS

A convenience sample of adult patients was recruited from the medical wards of a tertiary care facility. Baseline information at the time of hospital admission, subsequent diagnoses, and discharge instructions were recorded. Participants were prospectively followed with phone calls for six months after hospital discharge. Descriptive analyses were performed.

RESULTS

A total of 293 participants were enrolled in the study. Just under half (46%) of the participants were known to be living with HIV at the time of hospital admission. Most participants (97%) were given a referral for follow-up care; often that appointment was scheduled within two weeks of discharge (64%). Only 36% of participants returned to care within the first month, 50% returned after at least one month had elapsed, and 14% of participants did not return for any follow up.

CONCLUSIONS

Large discrepancies were found between the type of post-discharge follow-up care recommended by providers and what patients were able to achieve. The period of time following hospital discharge represents a key transition in care. Additional research is needed to characterize patients' risk following hospitalization and to develop patient-centered interventions.

Impact of Pharmacy Student-Driven Postdischarge Telephone Calls on Heart Failure Hospital Readmission Rates: A Pilot Program

Background: Heart failure (HF) hospitalization rates have remained high in the past 10 years. Numerous studies have shown significant improvement in HF readmission rates when pharmacists or pharmacy residents conduct postdischarge telephone calls. Objective: The purpose of this retrospective review of a pilot program was to evaluate the impact of pharmacy student-driven postdischarge phone calls on 30- and 90-day hospital readmission rates in patients recently discharged with HF. Methods: A retrospective manual chart review was conducted for all patients who received a telephone call from the pharmacy students. The primary endpoint compared historical readmissions, 30 and 90 days prior to hospital discharge, with 30 and 90 days post discharge readmissions. For the secondary endpoints, historical and postdischarge 30-day and 90-day readmission rates were compared for patients with a primary diagnosis of HF and for patients with a secondary diagnosis of HF. Descriptive statistics were calculated in the form of means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Results: Statistically significant decrease was observed for both the 30-day (P = .006) and 90-day (P = .007) readmission periods. Prior to the pharmacy students' phone calls, the overall group of 131 patients had historical readmission rates of 24.43% within 30 days and 38.17% within 90 days after hospital discharge. After the postdischarge phone calls, the readmission rates decreased to 11.45%, for 30 days, and 22.90%, for 90 days. Conclusion: Postdischarge phone calls, specifically made by pharmacy students, demonstrated a positive impact on reducing HF-associated hospital readmissions, adding to the growing body of evidence of different methods of pharmacy interventions and highlighting the clinical impact pharmacy students may have in transition of care services.

A Review of the Role of the Pharmacist in Heart Failure Transition of Care

This article reviews current literature on the role of pharmacists in the transition of care (TOC) for patients with heart failure (HF) and the impact of their contributions on therapeutic and economic outcomes. Optimizing the TOC for patients with HF from the hospital to the community/home is crucial for improving outcomes and decreasing high rates of hospital readmissions, which are associated with increased morbidity, mortality, and costs. A multidisciplinary team approach to the management of patients with HF facilitates the transition from the hospital to the ambulatory care setting, allowing for the consideration of medical, pharmacological, and lifestyle variables that impact the care of individual patients. Pharmacist participation on both inpatient and outpatient teams can provide a variety of services that have been shown to reduce hospital readmission rates and benefit patient management and treatment. These include medication reconciliation, patient education, medication dosage titration and adjustment, patient monitoring, development of disease management pathways, promotion of medication adherence, and postdischarge follow-up. In addition, as new pharmacologic treatments for HF become available, pharmacists can raise awareness of optimal drug use by maximizing education related to efficacy (e.g., adherence) and safety (e.g., potential side effects and drug interactions). Improving understanding of HF and its treatment will enable increased pharmacist involvement in the TOC that should lead to improved outcomes and reduced healthcare costs.

FUNDING

Novartis.

Clinic-Level Population Health Intervention by PGY2 Ambulatory Care Pharmacy Residents to Optimize Medication Management in a Self-Insured Employer Health Plan Population

BACKGROUND

Postgraduate year 2 ambulatory care pharmacy residents (PGY2 residents) may be able to improve healthcare quality by providing clinical pharmacy services provided to self-insured employer health plan patients. The objectives of this study are to describe this care delivery in a family medicine clinic, and to identify patients most likely to benefit from the service.

METHODS

From October 1, 2014 till June 30, 2015, comprehensive medication review was completed by PGY2 residents for patients insured by CU Anthem at the University of Colorado Westminster Family Medicine. For patients with medication-related problems (MRPs), a note was sent to the provider before the patient visit. Patient characteristics were compared in those who received a clinical pharmacy note with those who did not.

RESULTS

Sixty-eight MRPs were identified in 39 notes; 40 (58.8%) recommendations were implemented. The following Clinical Pharmacy Priority (CP2) score criteria were identified more frequently in patients with MRPs: age ≥65 years, diagnosis of diabetes, hypertension, chronic obstructive pulmonary disease, cardiovascular disease, blood pressure ≥140/90, hemoglobin A_1c >7.9%, and ≥6 items on the medication list.

CONCLUSION

PGY2 residents identified and resolved numerous clinically relevant MRPs. Patient-specific criteria can be utilized to target self-insured employer health plan patients who are likely to have clinically relevant MRPs.

An informatics-based approach to reducing heart failure all-cause readmissions: the Stanford heart failure dashboard

Background

Reduction of 30-day all-cause readmissions for heart failure (HF) has become an important quality-of-care metric for health care systems. Many hospitals have implemented quality improvement programs designed to reduce 30-day all-cause readmissions for HF. Electronic medical record (EMR)-based measures have been employed to aid in these efforts, but their use has been largely adjunctive to, rather than integrated with, the overall effort.

Objectives

We hypothesized that a comprehensive EMR-based approach utilizing an HF dashboard in addition to an established HF readmission reduction program would further reduce 30-day all-cause index hospital readmission rates for HF.

Methods

After establishing a quality improvement program to reduce 30-day HF readmission rates, we instituted EMR-based measures designed to improve cohort identification, intervention tracking, and readmission analysis, the latter 2 supported by an electronic HF dashboard. Our primary outcome measure was the 30-day index hospital readmission rate for HF, with secondary measures including the accuracy of identification of patients with HF and the percentage of patients receiving interventions designed to reduce all-cause readmissions for HF.

Results

The HF dashboard facilitated improved penetration of our interventions and reduced readmission rates by allowing the clinical team to easily identify cohorts with high readmission rates and/or low intervention rates. We significantly reduced 30-day index hospital all-cause HF readmission rates from 18.2% at baseline to 14% after implementation of our quality improvement program ( P  = .045). Implementation of our EMR-based approach further significantly reduced 30-day index hospital readmission rates for HF to 10.1% ( P for trend = .0001). Daily time to screen patients decreased from 1 hour to 15 minutes, accuracy of cohort identification improved from 83% to 94.6% ( P  = .0001), and the percentage of patients receiving our interventions, such as patient education, also improved significantly from 22% to 100% over time ( P  < .0001).

Conclusions

In an institution with a quality improvement program already in place to reduce 30-day readmission rates for HF, an EMR-based approach further significantly reduced 30-day index hospital readmission rates.

An Innovative Approach to Addressing the HIV Care Continuum: Implementation of a Clinical Pharmacy Resident in a Veterans Affairs HIV Specialty Clinic

PURPOSE

Engagement of patients in the HIV care continuum and adherence to antiretroviral therapy (ART) continue to limit successful viral suppression. Innovative practices to improve this continuum and ameliorate potential physician shortages are needed. The objective of this evaluation was to determine the clinical benefits of incorporating pharmacy resident involvement on a multidisciplinary team in caring for patients with HIV.

METHODS

A single-center pre-post cohort pilot evaluation was conducted at the Tennessee Valley Healthcare Systems VA Medical Center. Patients were enrolled in an HIV pharmacotherapy clinic implemented by an ambulatory care pharmacy resident. The primary end point of the evaluation was the percentage of patients achieving an undetectable plasma HIV viral load after enrollment. Secondary end points included change from baseline in CD4 T-cell count and self-reported adherence.

RESULTS

A total of 55 patients were seen in the HIV pharmacotherapy clinic over a 28-week evaluation period. Of those patients with detectable viral load at enrollment, 70% reached viral suppression during follow-up, with a significant 0.75 log10 decrease in the median viral load ( P < .0001 for both). The median CD4 T-cell count increased from 464 to 525 cells/mm³ ( P = .01). Reported adherence, assessed using the Visual Analogue adherence Scale (VAS) increased significantly ( P = .0001).

CONCLUSION

After enrollment in an HIV pharmacotherapy clinic, a significant decrease in viral load was seen, as were improvements in secondary end points of CD4 T cells and adherence. These data demonstrate the clinical benefits of pharmacy resident involvement on a multidisciplinary team in caring for patients with HIV.

Medication Optimization and Patient Education in Heart Failure: A Standardized Patient Case for Clerkship Students

INTRODUCTION

Heart failure is not only a common cause of hospitalization, it is also a condition associated with a high rate of readmission following discharge to home due to several factors including complex medication regimens. Medical management of patients with heart failure involves a number of monitoring parameters of which both physicians and patients must be aware, but are often not.

METHODS

In this exercise, clerkship students are presented with a patient scenario in which they are tasked with optimizing medication therapy as well as providing patient education regarding medications to engage and empower the patient to adhere to the prescribed regimen.

RESULTS

We found that students were most successful communicating the reason why medications were prescribed. Students exhibited similar performance regarding the likelihood of providing education regarding adverse drug events that could be anticipated. On the other hand, students were much less inclined to communicate appropriate monitoring and intensification information to patients.

DISCUSSION

Utilizing this case with third-year medical students highlights the need for additional opportunities for students to practice medication-related communication skills. In addition to its applicability to medical students, this case may also have utility in interprofessional education activities that involve learners from pharmacy or nursing programs who will be involved with reconciling, dispensing, educating, or administering medications to patients.