Advancing Pharmacy Practice through an Innovative Ambulatory Care Transitions Program at an Academic Medical Center.

Hospital readmissions are common and often preventable, leading to unnecessary burden on patients, families, and the health care system. The purpose of this descriptive communication is to share the impact of an interdisciplinary, outpatient clinic-based care transition intervention on clinical, organizational, and financial outcomes. Compared to usual care, the care transition intervention decreased the median time to Internal Medicine Clinic (IMC) or any clinic follow-up visit by 5 and 4 days, respectively.

Implementing Lean in Academic Primary Care.

Background: Lean is emerging as a quality improvement (QI) strategy in health care, but there has been minimal adoption in primary care teaching practices. This study describes a strategy for implementing Lean in an academic family medicine center and provides a formative assessment of this approach.

Methods: A case study of the University of North Carolina Family Medicine Center that used the Consolidated Framework for Implementation Research to guide a formative evaluation.

Implementation and evaluation of a pharmacist-led electronic visit program for diabetes and anticoagulation care in a patient-centered medical home.

Purpose: Results of a study evaluating quality-of-care, financial, and patient satisfaction outcomes of pharmacist-conducted telehealth visits for diabetes management and warfarin monitoring are reported.

Methods: A retrospective pre-post study was conducted to determine the impact of an electronic visit (e-visit) program targeting 2 groups of outpatients: adults with uncontrolled diabetes and warfarin-treated adults performing patient self-testing (PST) for monitoring of International Normalized Ratio (INR) values.

Results: A total of 36 patients participated in the e-visit program during the 2-year study period.

Post-Hospital Discharge Care: A Retrospective Cohort Study Exploring the Value of Pharmacist-Enhanced Care and Describing Medication-Related Problems.

Medication-related problems occur at high rates during care transitions. Evidence suggests that pharmacists are well-suited to identify and resolve medication-related problems during hospital admission and at discharge. Additional evidence is needed to understand the impact of face-to-face pharmacist visits in primary care after discharge.

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

Background: There is limited data describing the role of the patient-centered medical home (PCMH) in successful transitions programs and more information is needed to determine the transition points where pharmacist involvement is most impactful.

Methods: A family medicine center developed a multidisciplinary outpatient-based transitions program focused on reducing emergency department (ED) and hospital use in medically complex patients. Key team members were a medical provider, clinical pharmacist practitioner (CPP), and care manager.