Implementation of a Pharmacist-Managed Transitions of Care Tool.

Purpose: To improve, expand, and sustain a pharmacist-based transitions of care (TOC) program and to assess interventions targeting veterans at high risk for adverse outcomes.

Methods: A TOC program was developed and piloted at the Richard L. Roudebush Veterans Affairs Medical Center (RLRVAMC). Following success of the pilot project, targeted interventions were identified to improve and expand the program. Patients deemed high risk for readmission by an acute care pharmacist were identified and referred for continued postdischarge follow-up. The study population included patients discharged to the community with primary care established within the RLRVAMC system. Eligible patients were entered into a TOC database by the referring acute care pharmacist. A pharmacist in the primary care clinic reviewed then contacted the patient within 1 week of discharge. Appropriate documentation of each visit was completed in the electronic health record. Data collection included background information, time to follow-up, medication discrepancies, pharmacist interventions, emergency department visits, and hospital readmissions.

Results: A total of 139 patients were included, of which 99 patients were reached for pharmacist follow-up. There were 43 medication-related discrepancies among all patients. The most common discrepancy was taking the wrong dose of a prescribed medication. Additional counseling was provided to 75% of patients. The subset of patients who were reached by a pharmacist had decreased index (5.1% vs 15.0%; = .049) and all-cause readmissions (8.1% vs 27.5%; = .03) at 30 days compared with those who did not received pharmacist follow-up, respectively.

Conclusions: This study demonstrated that implementation and expansion of a pharmacist-based TOC process is effective in communicating high-risk patients and intervening on medication-related issues postdischarge.