Pharmacist-centered hospital to home care transition initiative improves patient outcomes

Purpose: To standardize and assess a transitions of care (TOC) model where the hospital pharmacist resolved medication discrepancies and medication-related problems in the inpatient and outpatient setting and reduced 30-day readmissions.

Methods: This quality improvement project utilized a hospital pharmacist to conduct TOC activities with general medicine patients during their hospitalization and after discharge to home. The pharmacist’s responsibilities included: (1) medication reconciliation on admission and discharge, (2) assessment of medication access and adherence problems, (3) medication education, and (4) telephone follow-up within 72 hours of discharge. Tools were developed to standardize patient interactions, assess medication access/adherence problems, and document in the inpatient and outpatient medical records. Primary outcomes were medication discrepancies in the inpatient and outpatient settings, medication-related problems after discharge, changes in H-CAHPS scores and 30-day readmission rates.

Results: 220 patients were included: mean age 58 years; 47% male; 53% Medicare; 5 median comorbid conditions; and 8 mean scheduled medications on admission. Pharmacists resolved a mean 3.6 medication discrepancies per patient on admission, with missing medications being most common (mean 1.5 per patient). Pharmacists reached 72% of patients after discharge and resolved a mean 1.7 medication-related problems per patient. H-CAHPS scores on new medication education and side effects improved significantly (22% to 75% and 27% to 75%, respectively) on this medicine unit when compared to before program initiation. Additionally, pharmacists identified a mean 7.8 medication discrepancies per patient when comparing the discharge medication list to the outpatient medical record. The most common outpatient discrepancy was missing medications (mean 3.7 per patient). Thirty-day readmissions were 11% for TOC patients compared to 24% for patients matched on age, sex, hospital service, and primary diagnosis.

Conclusion: This model that incorporates a hospital pharmacist conducting TOC activities is an effective approach to improve patient care and reduce 30-day readmissions.