Impact of a pharmacist in a transitional care clinic on readmission rates and adherence

Abstract

Objective: Research on factors affecting care of patient handoffs from a transitional care outpatient clinic (TCOC) visit to primary care physician (PCP) visit is limited. The Transitions of Care Consensus Conference recognizes the importance of outpatient transitions. The objective of this study is to assess the impact of interventions made by an ambulatory care pharmacist collaborating with a TCOC physician and community pharmacists to bridge the gap from TCOC to establishment of the initial PCP visit for patients recently discharged from the hospital. Methods: This is a prospective, sin- gle-center, cohort study of all patients seen in a TCOC at a federally qualified health center. TCOC meets on Tuesdays (physician visit only) and Thursdays (physician and pharmacist visit). The interventional arm will include 50 patients seen by the physician and pharmacist. These patients will receive pharmacistled chart review of recent hospitalization, medication reconciliation, phone calls to patient and pharmacy, education and adherence counseling, and recommendations on drug therapy problems and monitoring. Pillbox, medication reminder, and med-card with illustrative directions also will be provided. The control arm will be composed of 50 patients participating in a physician-only visit at TCOC. Data will be collected from the electronic medical record, TCOC visit, and pharmacy records and will include demographics, readmission and emergency department (ED) visit dates, fill history, drug therapy problems, and pharmacist interventions. The primary study outcome is all-cause 30-day readmission/ ED visit. Secondary outcomes include 30-day readmission/ED visit for reason of index hospitalization and medication adherence. Other outcomes are time duration of interventions and drug therapy problems and pharmacist interventions to mitigate these problems. Statistical analysis will utilize SPSS software. Study is pending institutional review board approval.