Embedding Clinical Pharmacy in Transitional Care: A Telehealth Comprehensive Medication Management Intervention for...

Hospital discharge is a high-risk period for patients with diabetes. Pharmacist-led comprehensive medication management (CMM) reduces hemoglobin A1c (HbA1c) in ambulatory settings, but structured telehealth CMM embedded within hospital-based transitional care platforms is rarely described. This article reports the implementation, fidelity, and observed outcomes of a telehealth CMM program for patients discharged with poorly controlled diabetes from a nonacademic hospital.

Using the Institute for Healthcare Improvement Model for Improvement, eight Plan-Do-Study-Act (PDSA) cycles (July 2024-July 2025) refined referral, enrollment, documentation, and follow-up workflows. Adults discharged from internal medicine with HbA1c > 8% and a hospital-affiliated provider were offered pharmacist telehealth visits at discharge, 30, and 60 days via a nurse-led warm handoff, at no cost through an in-kind partnership. Fidelity was tracked with run charts; outcomes were evaluated descriptively, with adjusted analyses in the supplement.

Of 361 eligible patients, 209 were approached; 113 enrolled (54.1% of those approached). Non-enrollment reflected out-of-network providers (n = 152) or unreachability (n = 77). Visit attendance declined from 87% (30 days) to 66% (60 days); a median of 69% of routed notes received a provider response. Pharmacists generated 185 approved recommendations (58.4% diabetes-related). Among patients with follow-up values, mean HbA1c declined from 10.8% to 7.7% (enrolled, n = 81) and from 10.3% to 8.8% (not enrolled, n = 113; p < 0.001 at follow-up), while acute care utilization was unchanged. Enrollment and outcome gaps were observed for Black patients and Medicare enrollees.

Embedding telehealth CMM within existing transitional care infrastructure was feasible without new inpatient staffing. Key lessons include the value of warm handoffs, the difficulty of reaching the highest-risk patients, and the need for equity-informed outreach.