Implementation of a pharmacist-led transitional care clinic.

Area of Science:

• Health Services Research
• Clinical Pharmacy Practice
• Patient Care Management

Background:

• High-risk patients frequently require readmission after hospitalization or emergency department (ED) visits.
• Transitional care is crucial for optimizing medication management and disease control in these vulnerable populations.
• Pharmacist-led interventions can address medication-related problems and improve patient outcomes.

Purpose of the Study:

• To describe the establishment and function of a pharmacist-led transitional care clinic (TCC).
• To evaluate the impact of the TCC on high-risk patients recently discharged from the hospital or ED.
• To assess the TCC's effectiveness in medication optimization and disease state management.

Main Methods:

• Establishment of a face-to-face and telephone follow-up TCC at the Memphis Veterans Affairs Medical Center (VAMC).
• Clinical pharmacy specialists (CPSs) provided medication reconciliation, compliance assessment, and adverse drug event evaluation.
• CPSs ordered diagnostic tests, performed physical assessments, and collaborated with other healthcare providers.

Main Results:

• The TCC saw patients within two weeks of discharge, referring them back to primary or specialty care.
• Retrospective data from 2016 showed a 7.8% 30-day readmission rate for TCC patients.
• Readmission rates for chronic obstructive pulmonary disease (COPD) and heart failure (HF) were reduced to 13% and 10%, respectively, compared to hospital-wide rates.
• Pharmacists documented an average of 6.2 interventions and 3.3 medication-related problems per patient.
• Telehealth appointments were implemented to increase access for rural and homebound patients.

Conclusions:

• A pharmacist-led TCC is effective in reducing hospital readmissions for high-risk patients.
• The TCC successfully prevented medication-related problems, improving disease state management.
• This model of care enhances post-discharge follow-up and patient outcomes.