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Clinical Pharmacy Specialists Provide Transitional Care and Improve Medication Safety After Discharge at Memphis Veterans Affairs Medical Center

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May 16, 2022
Summary

Post-discharge adverse drug events (ADEs) are one of the most common preventable harms leading to hospital readmission in the United States.1,2 To improve medication-related safety and reduce hospital readmissions, the Memphis Veterans Affairs Medical Center (VAMC) started a transitional care clinic (TCC) led by clinical pharmacy specialists (CPSs) who provide follow-up care to patients after they are discharged from the hospital or emergency department (ED). CPSs are independent mid-level practitioners who can manage and adjust patients’ medications, order laboratory tests, and perform traditional pharmacists’ duties. Previous studies have shown that pharmacist-led post-discharge transition services can be effective in reducing readmissions.3,4,5,6

The target population for this innovation included recently discharged patients considered high-risk for ADEs and readmission. Specifically, the population included:

  1. Patients admitted for heart failure (HF) exacerbation or chronic obstructive pulmonary disease (COPD) exacerbation,
  2. Patients who required timely follow-up for needs such as insulin titration, blood pressure management, and laboratory monitoring, and
  3. Patients admitted to the ED who were not linked to a primary care provider (PCP).

The TCC included a follow-up appointment roughly two weeks after patient discharge and help with care coordination. Services provided at the follow-up appointment included:

  • Medication adjustments
  • Medication reconciliation
  • Evaluation of ADEs
  • Physical examination
  • Lab and imaging test referrals
  • Specialist referrals
  • Referral to a PCP for those without a PCP
  • Patient education

To address challenges related to patient follow-through, the hospital staff emphasized the importance of scheduling TCC appointments before patient discharge from the hospital, providing reminder calls, and following up to reschedule if a patient missed their appointment.

A retrospective review over the course of a year following implementation of the TCC found the readmission rate for COPD was 13% and for HF was 10% for patients seen in the TCC, compared to hospital-wide readmission rates of 19% for COPD and 24% for HF.A propensity-matched analysis showed a nonsignificant reduction of 12.5 percentage points in the 30-day readmission rate in the TCC cohort versus the non-TCC cohort (3.1% vs. 15.6%; P = 0.196). While the results were nonsignificant, the authors note that after matching, the sample size was small (n = 32), and several TCC patients were excluded due to high propensity scores.7 The amount of time before patients were seen following discharge was six days shorter in the TCC group (P = 0.09). Pharmacists documented an average of 6.2 interventions and 3.3 medication-related problems per patient.7

The intervention was determined to be cost-effective due, in large part, to the prevention of hospital readmissions.7 According to the innovation team, Memphis VAMC expanded the services from once a week to three times a week and hired four additional CPSs.  

Innovation Patient Safety Focus

The focus of the innovation is to prevent post-discharge ADEs and 30-day hospital readmissions for patients with HF or COPD, and other patients deemed to be at high risk for readmission. ADEs are defined as harm experienced by a patient because of exposure to a medication and can be a result of patient nonadherence or prescriber error.8 Both ADEs and hospital readmissions are costly and preventable and are an important measure of healthcare quality and safety.5,9 To incentivize improved post-discharge transitional care, the Centers for Medicare & Medicaid Services imposes financial penalties on hospitals with the highest rates of readmission.

Resources Used and Skills Needed

According to the innovation team, the initiative requires:

  • A scheduling team and other ancillary staff
  • CPSs to see patients
  • Clear eligibility criteria and a referral process
  • Training for hospital and ED staff on the referral criteria and how to refer patients
  • Care coordination with the patient’s providers
  • Scheduling TCC appointments before the patient is discharged
    • CPSs may also contact the patient and begin education and post-discharge planning while the patient is still in the hospital.
  • Space and supplies (though Memphis VAMC was able to incorporate the TCC into existing infrastructure)
  • Flexibility to follow up with no-shows and provide same-day appointments
  • Telemedicine slots for patients with transportation challenges (e.g., homebound patients, patients in rural areas)
  • Linkages to providers for procedures outside the scope of the CPSs
  • Linkages to PCPs for patients without a PCP
Use By Other Organizations

The TCC was part of a larger trend amongst U.S. healthcare systems involving the use of pharmacists and other mid-level providers to administer transitional care. By leveraging the ability of other health care professionals/mid-level providers to practice at the top of their licensure, the TCC also one approach to try to optimize and reduce burden on primary care physicians.

Date First Implemented
2015
Problem Addressed

After discharge from the hospital, many patients experience medication errors and ADEs. In particular, patients that are elderly and medically complex, who make up a large portion of Veterans Affairs Medical Center (VAMC) patients, are at increased risk for ADEs.10 A systematic review found medication errors occur around half the time following discharge from the hospital.10 Nearly 20% of adult patients in studies evaluating medication errors were reported to be affected by ADEs after hospital discharge.11 Patient medication regimens are often changed while the patient is hospitalized, and this can lead to confusion about the changes after discharge, especially if there is a functional impairment.10 Despite the recognized importance of transitional care, the nationwide shortage of primary care physicians can limit patients’ access to transitional care.12

Readmission to the hospital is also a costly and common form of preventable harm. In 2018, there were a total of 3.8 million adult hospital readmissions within 30 days.13 The average cost of all-cause 30-day readmissions in the United States is around $15,000 per occurrence.14

Description of the Innovative Activity

This pharmacist-led TCC focused on high-risk patients (e.g., patients with ambulatory care-sensitive conditions) who were recently hospitalized or seen in the emergency department (ED). Patients without a PCP were also included. Hospital and ED staff referred patients that met the TCC criteria to TCC staff who attempted to schedule a follow-up appointment within two weeks of discharge.

At the appointment, CPSs provided many services, including adjusting medications, managing medications, conducting limited physical exams (e.g., taking vitals, listening for heart abnormalities), ordering and interpreting laboratory values, ordering consults for appropriate follow-up, and performing traditional pharmacists’ duties (including patient education). After the TCC appointment, patients were discharged to their primary care team or specialty provider for further care management.

To reduce TCC appointment no-shows, the TCC team asked hospital providers and the administrative team to emphasize the importance of attending TCC appointments. For rural and homebound patients, TCC services were expanded to include telehealth appointments utilizing both phone and video conferencing modalities to increase access. The TCC also consulted telehealth nursing services to further support care coordination. After care with the TCC, once certain patients were linked to, and had the technology to work with, telehealth nurses, the telehealth nurses were able to continue to monitor patients with diabetes, hypertension, and HF remotely and alert their providers of any issues or concerns.

During the years after the TCC was implemented, the innovation team estimates that Memphis VAMC experienced a 5% to 10% reduction in readmissions utilizing TCC, which equates to an avoiding cost of $864,000 to $1.7 million each year.7 The creation of the TCC did not incur any costs, as existing infrastructure and personnel were used for operations.

Due to the experiences and outcomes from the first couple of years of the initiative, the TCC initially expanded from once a week to three times a week. Additionally, the Memphis VAMC hired four CPSs to expand transitional care services to the inpatient medicine teams. The expansion increased access to pharmacy services to mitigate issues before discharge, such as ensuring appropriate medication reconciliation and facilitating appropriate outpatient follow-up. Additionally, these inpatient pharmacists focused on disease state counseling for high-risk patients at discharge, like those patients frequently seen in the TCC. Lastly, the TCC expanded to a clinical service provided by ambulatory care CPSs embedded within the patients’ primary care teams, allowing for improved daily access and communication with the primary care providers.

Context of the Innovation

The Affordable Care Act created the Hospital Readmissions Reduction Program, which financially penalizes hospitals that exceed certain 30-day readmission rates for several high-risk chronic diseases.15 Patients served by U.S. Department of Veterans Affairs (VA) hospitals have higher readmission rates for common conditions than patients served by non-VA hospitals.16 At the time of the intervention, the Memphis VAMC had a 30-day readmission rate of 15%, with a hospital stay costing $3,600 per day.7 Heart failure and COPD are two of the top causes for hospital readmissions.13

To address these issues, transitional care initiatives have been implemented by the VA and other health systems. These have been shown to contribute to decreased costs and improved veteran satisfaction with their care experience.17 In particular, pharmacists have been shown to play a role in reducing readmissions.18 This is important because the nationwide shortage of PCPs, which is expected to increase in coming years, is impacting patient safety and quality of care, and other clinician types can help fill in gaps.12

The Memphis VAMC serves veterans living in a 53-county tri-state area (Tennessee, Arkansas, and Mississippi). Most of the patient population consists of elderly veterans, often with multiple comorbid diseases and complex medication regimens.

Results

During 2016, 7.8% of all patients seen in the TCC were readmitted within 30 days of discharge. TCC readmission rates for HF and COPD were 13% and 10% respectively, compared to hospital wide rates of 17% and 24% to, respectively.7 A separate observational matched analysis (n = 114) found that 30-day readmissions for COPD and HF were reduced by 12.5 percentage points in the TCC cohort vs. the non-TCC cohort (3.1% vs. 15.6%; P = 0.196).7

The same study found that the average time between discharge and TCC visit was 15 days, roughly six days less than the follow-up time experienced by non-TCC patients.7 Pharmacists documented an average of 6.2 interventions and 3.3 medication-related problems per patient. Medication-related interventions accounted for over half of the interventions.

Planning and Development Process

The innovation team suggests that when planning the innovation, sites should first identify the problem and target population, plan how the intervention will fit into other processes, consider what data to collect, and determine staffing needs and the need for scheduling follow-up.

Resources Used and Skills Needed

According to the innovation team, the initiative requires:

  • A scheduling team and other ancillary staff
  • CPSs to see patients
  • Clear eligibility criteria and a referral process
  • Training for hospital and ED staff on the referral criteria and how to refer patients
  • Care coordination with the patient’s providers
  • Scheduling TCC appointments before the patient is discharged
    • CPSs may also contact the patient and begin education and post-discharge planning while the patient is still in the hospital.
  • Space and supplies (though Memphis VAMC was able to incorporate the TCC into existing infrastructure)
  • Flexibility to follow up with no-shows and provide same-day appointments
  • Telemedicine slots for patients with transportation challenges (e.g., homebound patients, patients in rural areas)
  • Linkages to providers for procedures outside the scope of the CPSs
  • Linkages to PCPs for patients without a PCP
Funding Sources

The TCC was supported with resources and the use of facilities at the Memphis VAMC.

Getting Started with This Innovation

To get started with the innovation, the innovation team suggests the following:

  • Identify the patient population that most needs an intervention.
  • Establish the innovation transition care pathway within the array of transition referral options.
  • Establish criteria for the target population.
  • Educate the hospital clinical staff on the importance of transitional care and the need to encourage patients to follow through with TCC appointments.
  • Organize and train support staff.
  • Implement data collection processes.
  • Implement systems that allow flexibility.
  • Develop relationships and systems for handoffs and referrals.
Sustaining This Innovation

To be sustainable, the innovation team recommend that a CPS-led TCC clinic for high-risk patients should:

  • Establish strong relationships with hospital and ED staff to coordinate referrals.
  • Address patient follow-through issues. In this case, CPSs worked with inpatient providers and scheduling staff to relay the importance of TCC appointments.
    • Additionally, the TCC suggests scheduling patients prior to discharge, so that the TCC appointment is listed on the patients’ discharge instructions.
  • Provide patients with individualized education about their disease and medications prior to discharge.
  • Ensure adequate support staff.
  • Offer same-day appointments for ED patients with acute counseling or medication needs in order to prevent admissions.
  • Provide appointment reminders, including calls the day before an appointment.
  • Contact patients if they miss their appointments. 
  • Attempt to increase access using telehealth appointments and same-day appointments.
  • Be able to pull in more pharmacists to cover if the need increases.
  • Attempt to see patients within two weeks of discharge.
  • Remember the importance of addressing a patient’s clinical issues and concerns on the front end, either before or immediately after patient discharge, to prevent ADEs and other harmful events.
References/Related Articles

Anderson SL, Marrs JC. A review of the role of the pharmacist in heart failure transition of care. Adv Ther. 2018;35(3):311-323. doi:10.1007/s12325-018-0671-7.

Cavanaugh JJ, Lindsey KN, Shilliday BB, Ratner SP. Pharmacist-coordinated multidisciplinary hospital follow-up visits improve patient outcomes. J Manag Care Spec Pharm. 2015;21:256-260. doi:10.18553/jmcp.2015.21.3.256.

Dempsey J, Gillis C, Sibicky S, et al. Evaluation of a transitional care pharmacist intervention in a high-risk cardiovascular patient population. Am J Health-Syst Pharm. 2018;75(17 Supplement 3):S63-S71.

Hale GM, Hassan SL, Hummel SL, Lewis C, Ratz D, Brenner M. Impact of a pharmacist-managed heart failure post discharge (bridge) clinic for veterans. Ann Pharmacother. 2017;51(7):555-562.

Layman SN, Elliott WV, Regen SM, Keough LA. Implementation of a pharmacist-led transitional care clinic. Am J Health Syst Pharm. 2020 Jun 4;77(12):966-971. doi:10.1093/ajhp/zxaa080. PMID: 32374382.

Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). J Hosp Med. 2016;11(1):39-44. doi:10.1002/jhm.2493.

Footnotes
  1. Panagioti M, Khan K, Keers R N, Abuzour A, Phipps D, Kontopantelis E et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis BMJ 2019; 366 :l4185 doi:10.1136/bmj.l4185
  2. Feigenbaum P, Neuwirth E, Trowbridge L, Teplitsky S, Barnes CA, Fireman E, Dorman J, Bellows J. Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals. Medical care. 2012 Jul 1:599-605.
  3. Salas CM, Miyares MA. Implementing a pharmacy resident run transition of care service for heart failure patients: effect on readmission rates. Am J Health Syst Pharm. 2015;72(11 Suppl 1):S43-S47. doi:10.2146/sp150012.
  4. Anderegg SV, Wilkinson ST, Couldry RJ, Grauer DW, Howser E. Effects of a hospitalwide pharmacy practice model change on readmission and return to emergency department rates. Am J Health Syst Pharm. 2014;71(17):1469-1479. doi:10.2146/ajhp130686.
  5. Moye PM, Chu PS, Pounds T, Thurston MM. Impact of a pharmacy team-led intervention program on the readmission rate of elderly patients with heart failure. Am J Health Syst Pharm. 2018;75(4):183-190. doi:10.2146/ajhp170256.
  6. Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study). J Hosp Med. 2016;11(1):39-44. doi:10.1002/jhm.2493.
  7. Layman SN, Elliott WV, Regen SM, Keough LA. Implementation of a pharmacist-led transitional care clinic. Am J Health Syst Pharm. 2020 Jun 4;77(12):966-971. doi:10.1093/ajhp/zxaa080. PMID: 32374382.
  8. Patient Safety Network. Medication errors and adverse drug events: background and definitions. Agency for Healthcare Research and Quality. September 7, 2019. https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events#Background-and-Definitions. Accessed March 16, 2022.
  9. Agency for Healthcare Research and Quality. Hospital readmissions.
  10. https://www.ahrq.gov/topics/hospital-readmissions.html#accordions. Accessed March 16, 2022.
  11. Parekh N, Ali K, Page A, Roper T, Rajkumar C. Incidence of medication-related harm in older adults after hospital discharge: a systematic review. J Am Geriatr Soc. 2018;66(9):1812-1822. doi:10.1111/jgs.15419.
  12. Alqenae FA, Steinke D, Keers RN. Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: a systematic review. Drug Saf. 2020;43(6):517-537. doi:10.1007/s40264-020-00918-3.
  13. Zhang X, Lin D, Pforsich H, Lin VW. Physician workforce in the United States of America: forecasting nationwide shortages. Hum Resour Health. 2020;18(1):8. doi:10.1186/s12960-020-0448-3.
  14. Weiss AJ, Jiang HJ. Overview of clinical conditions with frequent and costly hospital readmissions by payer, 2018. Agency for Healthcare Research and Quality, US Dept of Health and Human Services; 2021. Healthcare Cost and Utilization Project (HCUP) Statistical Brief #278. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb278-Conditions-Frequent-Readmissions-By-Payer-2018.jsp. Accessed March 16, 2022.
  15. Bailey MK, Weiss AJ, Barrett ML, Jiang, HJ. Characteristics of 30-day all-cause hospital readmissions, 2010–2016. Agency for Healthcare Research and Quality, US Dept of Health and Human Services; 2019. Healthcare Cost and Utilization Project (HCUP) Statistical Brief #248. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb248-Hospital-Readmissions-2010-2016.jsp. Accessed March 16, 2022.  
  16. Centers for Medicare & Medicaid Services. Hospital Readmissions Reduction Program (HRRP). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program. Accessed March 16, 2022.
  17. Nuti SV, Qin L, Rumsfeld JS, et al. Association of admission to Veterans Affairs hospitals vs non-Veterans Affairs hospitals with mortality and readmission rates among older men hospitalized with acute myocardial infarction, heart failure, or pneumonia. JAMA. 2016 Feb 9;315(6):582-92. doi:10.1001/jama.2016.0278. PMID: 26864412; PMCID: PMC5459395.
  18. Messina W. Decreasing congestive heart failure readmission rates within 30 days at the Tampa VA. Nurs Adm Q. 2016;40(2):146-152. doi:10.1097/NAQ.0000000000000154.
  19. Cavanaugh JJ, Lindsey KN, Shilliday BB, Ratner SP. Pharmacist-coordinated multidisciplinary hospital follow-up visits improve patient outcomes. J Manag Care Spec Pharm. 2015;21(3):256-260.
The inclusion of an innovation in PSNet does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or of the submitter or developer of the innovation.
Contact the Innovator

Sara Layman, PharmD, BCPS, Clinical Pharmacy Specialist in Internal Medicine/Transitional Care

Sara.layman@va.gov

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