Implementation of a Pilot Pharmacist-Led Post-Discharge Transitions of Care Service

Background: With the increase in prevalence of many chronic disease states requiring ambulatory care management and the complicated medication regimens that follow suit, there has become a pressing need for improved healthcare collaboration with medication reconciliation in an effort to ensure positive patient outcomes and safety. We implemented a quality improvement initiative involving recently discharged patients from the Family Medicine Service from OSU Medical Center, utilizing a pilot telephonic pharmacist-led transitions of care program to assess the feasibility and impact of the program.

Methods: This is an IRB approved, quasi-experimental quality improvement initiative. Patients were included in the study if they were documented English-speaking adults at least 18 years of age or older at the time of admission, who were discharged from inpatient Family Medicine Services at OSUMC, had an available discharge summary including a medication list(s), and received outpatient primary care from any provider at any of the three OSU FM Clinics. Patients were excluded from this study if pregnancy was documented during their admission or any time during the study period, or were discharged to a nursing home, psychiatric facility, prison or jail facility, skilled nursing facility (SNF), or long-term acute care (LTAC) facility.

Charts for patients who met inclusion criteria for this study were reviewed within both the clinic and hospital EHR to identify and document baseline demographic information and medication discrepancies that occurred since the time of hospital discharge. These patients then received pharmacist-led transitions of care services, which consisted of a detailed medication reconciliation, and a telephone interview within 72 business hours of discharge from OSUMC. Telephone interviews were attempted a maximum of three times. A telephone note was documented for each call within the Family Medicine Clinic’s EHR system to describe the encounter and include any potential recommendations or considerations to address at the patient’s follow-up visit with their physician.

Results: There were 189 patient discharges identified, 13 of these discharges met exclusion criteria, and 87 discharges did not answer. There were 9 readmissions in the 89 patient discharges. A total of 17 and 13 errors were identified upon discharge and during the patient phone call, respectively. The top three categories of errors identified upon discharge included incorrect duration, dose, or drug selection. The missed doses/barrier to access made up half of the errors identified during the patient phone calls.

Conclusion: During this project, we identified and corrected errors using medication reconciliation, clinical interventions, and patient education. Implementing this pharmacist-led transitions of care program allowed for improved healthcare collaboration with patients and primary care providers to ensure optimal medication-related patient outcomes, safety and adherence, with the goal of preventing hospital readmissions.