Evaluating a multi-disciplinary approach in a primary care setting to decrease hospital readmission rates and medication-related issues after hospital discharge

Purpose: This quality-improvement study aimed to: 1) evaluate the clinical effectiveness of a multi-disciplinary transition of care model in a primary care setting, in combination with social workers and clinical pharmacists, and 2) recognize the role of the clinical pharmacists in identifying and resolving health, medication, or social-related concerns in order to decrease preventable hospital readmissions

Methods: Between October 1, 2011 to March 31, 2012, established patients of two general internal medicine resident clinics at The University of Pennsylvania Health System were seen in the post-acute care clinic (PACC) if their primary care provider was not available within 1-2 weeks of hospital discharge.  First, the pharmacist conducted a medication reconciliation visit and communicated any concerns to the examining physician.  Each medication issue was assigned a severity level: I - minor (non-life threatening and unlikely to have adverse outcomes), II - moderate (non-life-threatening but could interfere with therapeutic goals), and III - severe (potentially life-threatening if left unaddressed).  Patients’ charts were reviewed to verify hospital readmission thirty days after discharge.

Results: A total of 226 out of 371 patients showed for the PACC appointment.  Of these, 84% of patients who met with a pharmacist had at least one medication-related issue identified.  Furthermore, 26%, 51%, and 7% had a potential medication issue severity level of I, II, and III, respectively. Thirty day readmission rates for patients scheduled in PACC from October 2011 to March 2012 declined from 20% to 8%, respectively.  The all-cause readmission rate for the health system from July 2011 to March 2012 was 25%.  

Conclusion: Using a multi-disciplinary transitions-of-care model in a primary care setting, in combination with clinical pharmacists, may be an effective way to decrease preventable hospital readmission, improve patient safety, optimize medication use, and avoid medication errors.