Title: Lost in transition: the benefit of interdisciplinary home-based care following hospitalization

Purpose:  Idaho has the lowest national 30-day re-hospitalization rate for Medicare beneficiaries at 13.3%, which may be misleading due to limited access to care. A home-based Transition of Care (TOC) clinic was developed to provide safe and effective transitions from acute care to home by utilizing a unique interdisciplinary team of nurse practitioner, clinical pharmacist, and health professions students with electronic medial record (EMR) access in the home; drug-related problems (DRPs) were identified.

Methods: An office-based interdisciplinary TOC clinic was developed in 2006 but evolved into a semi-weekly home-based service in 2011 due to high no-show rates and an inability to thoroughly identify and resolve DRPs. Enrollment criteria for the home-based TOC program included inpatient hospitalization > 48 hours, age ≥ 65 and one additional risk factor (e.g. ≥ 2 hospitalizations in the past 6 months, ≥ 2 chronic illnesses, polypharmacy, ≥ 2 medication changes, documented history of poor adherence). Services provided were assessment for DRPs, medication counseling and reconciliation, personal medication record development, clinical assessment, depression/dementia screening, fall risk assessment, and assistance with advanced directives. An interim retrospective EMR chart abstraction of documented hospital follow-up was performed to compare DRPs identified at TOC and provider office visits.

Results:  From October 17, 2011 to June 15, 2012, there were 55 home-based TOC encounters.  Interim analysis identified 2.6 DRPs documented per TOC clinic encounter compared to 0.6 DRPs per provider office encounter (p = 0.023).  The most common DRPs in TOC clinic were secondary to unintentional/intentional non-adherence, incomplete/inaccurate discharge instructions, therapy duplication, and provider-provider/provider-patient miscommunication. A 12-month analysis of identified and classified DRPs and 30-day re-hospitalization rates will be presented.

Conclusion: An interdisciplinary home-based TOC clinic is effective at identifying DRPs. Although cost-prohibitive in many areas, interdisciplinary home-visit TOC delivery should be further explored.