Impact of a pharmacist-driven transitions of care clinic for a multisite integrated delivery network.

PURPOSE: To assess the impact on readmission rates for CMS core measures (CCM) patients and patients receiving care under the Bundled Payment for Care Improvement (BPCI) Advanced Model resulting from implementing a pharmacist-led transitions of care (TOC) clinic in central Florida.

METHODS: These study cohorts consisted of patients in 2 strata (CCM and BPCI), and pre-post comparisons were conducted within each stratum. CCM and BPCI patient stratification was based on diagnoses. Patients referred to the TOC clinic were identified and compared to patients who did not receive TOC clinic services in the prior year. The pharmacist-led TOC clinic services consisted of a postdischarge telephone interview by a pharmacist to identify TOC barriers. Pharmacists in the TOC clinic conducted medication reconciliations, provided education, and completed follow-up telephone visits to mitigate these barriers. The primary outcome was the 30-day readmission rate for CCM patients and 90-day readmission rate for BPCI patients. The secondary outcomes were the numbers and types of interventions performed in the pharmacist-led TOC clinic.

RESULTS: A total of 1,203 patients met the inclusion criteria for the CCM stratum. The CCM post-group had an overall reduction in the rate of 30-day readmission relative to the pre-group (6.25% vs 13.29%, P < 0.0327). A total of 1,416 patients met the inclusion criteria for the BPCI strata. Relative to the BPCI pre-group, the BPCI post-group had an overall reduction in occurrence of 90-day readmission (17.27% vs 25.61%, P < 0.0306). Clinical pharmacists performed 456 interventions in the CCM and BPCI post-groups, with an average of 2 interventions per patient.

CONCLUSION: A pharmacist-driven TOC clinic was associated with significant reductions in 30-day CCM and 90-day BPCI hospital readmissions.