Background: Memorial Healthcare System (MHS) participated in the Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement Advanced value-based program aimed to improve patient care and reduce health care costs. Challenges with medication therapy problems (MTPs) led to the development of a centralized tele-health population health pharmacy program. This innovative approach aimed to provide comprehensive postdischarge medication support and resolve MTPs during the 90-day risk period.
Objectives: The program aimed to provide longitudinal medication support, resolve MTPs, and affect 90-day readmission rates.
Practice Description: MHS established uniform workflows, a pharmacy task force, and a dual pharmacy team approach with population health registered nurses (PHRNs). The population health pharmacists (PHPs) conducted postdischarge telephonic encounters to resolve MTPs longitudinally throughout the risk period.
Practice Innovation: The program used a centralized tele-health model with electronic health record-integrated tools. It targeted readmission rates up to 90 days, beyond the conventional 30-day period. PHPs collaborated with onsite transitions of care pharmacists, PHRNs, and health care professionals for coordinated patient care and MTP resolution.
Evaluation Methods: A retrospective analysis using descriptive statistics, a Kruskal-Wallis test, and multivariate regression models after stratifying patients into 4 groups were used to assess MTP resolution rates and differences in readmission rates.
Results: Over 7 months, PHPs completed 801 telephonic visits, identifying 433 MTPs with a 94% resolution rate. The program led to a statistically significant reduction in 90-day readmission rates from 35% to a range of 10%-17% (P < 0.01).
Conclusion: The centralized tele-health population health pharmacy program improved patient outcomes, resolved MTPs, and reduced readmission rates. The program serves as a model for integrating pharmacists into value-based care initiatives.
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| http://dx.doi.org/10.1016/j.japh.2023.09.008 | DOI Listing |
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