Daryl Miller, Pharm.D. , Josephine Cheng, Pharm.D., Mary Lomberk, Pharm.D., Jennifer Kearns, Pharm.D., Timothy Bach, Pharm.D., Lacey Charbonneau, Pharm.D., Timothy L’Hommedieu, Pharm.D., M.S.
BayCare Health System, Clearwater, FL
Medication therapy is the primary modality used to manage active disease states and maintain patient health. With pharmacotherapy playing a significant role in the treatment strategy for patients discharged from hospitals, the opportunity to leverage clinical pharmacists was recognized in the BayCare Health System. The Pharmacy Transitions of Care Program (PTOC) was developed to improve patient outcomes with specific emphasis on 30 day hospital readmissions.
The PTOC is driven by ambulatory trained pharmacists who are integrated within BayCare’s hospitals and collaborate with inpatient and outpatient care teams. The program includes 2 patient encounters after discharge: a telephonic encounter within 7 days of discharge and a second encounter 21 days after discharge. During these follow up calls, pharmacists evaluate patient clinical status, provide a comprehensive medication review, counsel on medications, and engage in medication therapy management to intervene on any problems or opportunities identified during the encounter. Target patients for the PTOC program are Medicare Part A and B beneficiaries with a primary diagnosis of a CMS core measure who are discharged to the home setting or to an assisted living facility.
The PTOC program was initially piloted in August 2015 at one hospital. Given the success of the pilot, the program was scaled across the health system to serve all eleven hospitals. The primary outcome is 30-day readmission and secondary outcomes are pharmacist interventions. Data was collected and analyzed from September 2016 to May 2017. Patients enrolled in the PTOC program were compared to those who met criteria, but were unable to be reached by a transitions of care pharmacist. During the study period, 2,286 patients were enrolled. The control group comprised of 1,335 patients. The readmission rate for the study group was 8.3% (N = 190), compared to 23.7% in the comparison group (N=317), a statistically significant difference (p <0.001). Pharmacists documented a total of 13,855 interventions including 1,503 contacts to members of the interdisciplinary team, 175 medication assistance programs enrolled, and 12,177 counseling interventions.
The PTOC is an innovative model that utilizes the talent and expertise of pharmacists to improve and optimize patient care. This program demonstrated a statistically significant reduction of all-cause 30-day readmissions and reduced them by more than 64%. The program continues to produce consistent and sustained hospital readmission rates.
