Pharmacist-Directed Transition of Care Services Decrease Readmissions at a Safety-Net Hospital.

Area of Science:

• Health Services Research
• Pharmacy Practice
• Patient Outcomes

Background:

• Limited data exists on pharmacist-led transition of care (TOC) services in safety-net hospitals.
• Safety-net populations often face complex health and social challenges, including housing instability, substance use disorder (SUD), and mental health issues.

Purpose of the Study:

• To assess the impact of pharmacist-led TOC services on hospital readmissions.
• To evaluate these services in a high-risk managed Medicaid population within a safety-net hospital setting.

Main Methods:

• Retrospective evaluation of 292 patients receiving TOC services between January 2022 and December 2022.
• Interventions included initial visits, medication delivery/education, and post-discharge follow-up calls.
• Primary outcome was 30-day hospital readmissions; secondary outcomes included readmission reasons.

Main Results:

• Median readmission rate decreased from 20.2% to 12.3% post-intervention.
• Substance use disorder was the leading cause of readmission (58%).
• Six readmissions (16.7%) were medication-related, five complicated by SUD; none were preventable.

Conclusions:

• Pharmacist-led TOC discharge services show potential for reducing hospital readmissions in socially complex managed Medicaid populations.
• These findings highlight the value of TOC services in safety-net hospital settings for vulnerable patient groups.