Formative Evaluation of a Pharmacist-Led Area Agency on Aging Community Care Transition Initiative: A Qualitative...

The Michigan Region VII Area Agency on Aging (AAA) conducted a community care transition initiative (CCTI) for rural, low-income older adults to reduce hospital readmission rates. The AAA CCTI included a community health worker (CHW) home visit, pharmacist telehealth comprehensive medication review, and follow-up after discharge. Our study aimed to conduct a formative evaluation of the AAA CCTI to identify areas for program refinement. Identified strategies for program refinement add to the development, implementation, and evaluation of rural care transition program literature.

We conducted a qualitative study using semistructured interviews with key AAA CCTI informants via Zoom. Qualitative content analysis was used to identify categories related to existing resources, inputs needing adjustment, delivery of planned procedures, suggested procedural changes, and client responses.

Five AAA CCTI staff members participated in an interview. The program's resources included AAA reputation, qualified CHWs, and strong external networks. The inputs needing adjustment were funding sustainability, CHW preparation, and the availability of key personnel. The implemented procedures were: CHWs receiving standard training, connecting clients with diverse external resources; an efficient combination of CHW home visits and telehealth pharmacist visits; in-depth CHW home visits; promoting the program to strengthen partnerships; serving older adults at considerable risk of readmission; streamlining recruitment; and person-centered care. The suggested procedure changes included adjusting the follow-up duration and frequency, implementing strategies to improve sustainability, and providing the program to broader populations. Most clients accepted and were satisfied with the program, while a few declined home visits.

Our study provided a formative evaluation of the AAA CCTI to inform program refinement. Recommended refinements include adding pharmacist personnel, providing ongoing CHW training, and advocating for pharmacist-led care transitions. Our findings suggest including pharmacist telehealth during CHW home visits, in-person recruitment, and community resource referrals in rural care transition programs.