Impact of a transitions of care pilot service established by pharmacy residents within an academic medical center.

Objectives: The impact of a pharmacy postgraduate year (PGY)-2 resident-led transitions of care (TOC) pilot service targeting patients with chronic obstructive pulmonary disorder (COPD) and heart failure (HF) was evaluated in terms of 30-day hospital readmissions (primary objective) at the University of Louisville Hospital (ULH) and 30-day emergency department (ED) visits at ULH (secondary objective).

Setting: The study was conducted at an urban academic teaching hospital.

Practice Description: Before this pilot service, there were no formal TOC services for patients at high risk for readmission to ULH.

Practice Innovation: The TOC pilot service providing coverage 16 h/week included patients aged at least 18 years admitted to the ULH internal medicine team with a primary or secondary diagnosis of COPD or HF. Patients to be discharged to a location other than home or who could not be contacted after discharge were excluded. The service consisted of pharmacist-patient interactions before discharge; within 72 hours after discharge, over the telephone; and 7-14 days after discharge, in person.

Evaluation: Data were collected by retrospective chart review from patients enrolled between November 2017 and October 2018. For comparison, a computer-generated report identified patients who met the criteria for the pilot service but could not be enrolled.

Results: Of the 23 patients enrolled in the TOC pilot service, none required readmission to ULH within 30 days, compared with 12.3% of all other eligible patients. Similarly, no patients enrolled in the TOC pilot service presented to the ED within 30 days after discharge, compared with 18.6% of the comparator group. Completion rates of postdischarge follow-up were 65.2% for the telephone call and 52.2% for the clinic visit.

Conclusion: PGY-2 ambulatory care pharmacy residents implemented a new TOC service that contributed to lower rates of 30-day readmissions and ED visits than those for other eligible patients.