Accountable Care in Transitions (ACTion): A Team-Based Approach to Reducing Hospital Utilization in a...

Area of Science:

• Health Services Research
• Pharmacy Practice
• Primary Care

Background:

• Limited data exists on the patient-centered medical home's (PCMH) role in transitions of care programs.
• Further research is needed to identify optimal pharmacist intervention points during patient transitions.

Purpose of the Study:

• To evaluate an outpatient-based transitions program's impact on reducing emergency department (ED) and hospital utilization in medically complex patients.
• To identify predictors of 30-day rehospitalizations within this program.

Main Methods:

• A multidisciplinary team, including a medical provider, clinical pharmacist practitioner (CPP), and care manager, implemented the program.
• Utilization data (ED visits, hospitalizations, clinic visits) were compared before and after the intervention.
• Patient and process characteristics were analyzed for predictors of 30-day rehospitalizations.

Main Results:

• The program led to significant reductions in 30-day rehospitalizations at 14 and 30 days post-discharge.
• Reductions in ED visits and hospitalizations, alongside increased clinic visits, were observed at 1, 3, and 6 months.
• Clinical pharmacist practitioner (CPP) involvement was associated with significantly lower rehospitalization rates (7.7% vs 18.8%).

Conclusions:

• A multidisciplinary, outpatient-based transitions program within a PCMH can improve primary care access and decrease hospital and ED utilization.
• Integrating CPPs into transitions of care significantly reduces patient rehospitalizations.
• This model offers a standardized approach for managing complex care needs, potentially reproducible in other medical homes.