Enhancing Clinical Pharmacy Specialist Involvement in Transitions of Care Focusing on Ambulatory Care Sensitive Conditions within a Veterans Affairs Healthcare System

Abstract

The purpose of this quality improvement project was to evaluate the impact of clinical pharmacy specialist (CPS) involvement in the post-discharge period on 30-day readmission rates within a Veterans Affairs Healthcare System. Patients eligible for inclusion were discharged from a Veterans Affairs (VA) acute care facility with a principle or secondary diagnosis of heart failure (HF), chronic obstructive pulmonary disease (COPD), or both HF and COPD from 15 October 2018 through 14 January 2019. CPSs functioning as a mid-level provider with a scope of practice conducted telephone and in-clinic medication management appointments within 7 and 21 days post-discharge for qualifying patients discharged with a principle or secondary diagnosis of HF or COPD. CPS appointments focused on medication reconciliation, ensuring continuity of care, disease state counseling, and medication management. By enhancing the role of the CPS in the post-discharge period, there was an observed decrease in 30-day COPD index (p = 0.35), HF index (p = 0.23), and all-cause (p = 0.62) readmission rates from pre- to post-intervention. The results of this intervention show that CPS intervention in the post-discharge period may reduce index and all-cause readmission rates for patients discharged with a principle or secondary discharge diagnosis of COPD or HF.

Continuity of care after hospitalization due to cardiac conditions : Patients' perceptions, validity and reliability of a measure, and associations with outcomes

“…Several studies have evaluated the positive clinical effects of continuity of care, or interventions facilitating continuity of care, for patients with cardiac conditions. These clinical effects include reduced mortality and complications [29][30][31][32] , reduced healthcare utilization and fewer hospitalizations [32][33][34][35][36][37] , reduced 30-day readmission rate 29,32,[38][39][40][41][42][43][44][45][46] , reduced visits to the emergency department 32,34,37,45 , and shorter lengths of hospital stay (LOS) 29,31,47 . In addition, insufficient continuity is associated with inappropriate prescription medications (i.e., the use of drugs that should be avoided due to the high risk of adverse events) in patients with comorbidity 37 and serious adverse drug reactions in patients with atrial fibrillation using oral anticoagulation 48,49 .…”

“…Interventions to improve continuity of care for patients with cardiac conditions after discharge from hospital include pharmacist-driven, patient navigator-led, nurse-led, and complex interventions. Pharmacist-driven interventions involving patients with cardiac conditions have focused on ensuring continuity of care through medication reconciliation, patient counseling, follow-up, and setting health-related goals for patients [38][39][40] .…”

“…It is difficult to compare the results in relation to cardiac diagnoses with previous studies. Some studies on continuity of care do not report specific diagnoses 182 , only include one diagnosis 17,[29][30][31][42][43][44]180 , only include one cardiac condition 33,34,37,40,41,89 or do not present their findings in a way that makes a comparison between diagnoses possible 38 . However, Valaker et al 180 found that patients with an acute clinical pathway, such as those hospitalized due to STEMI, perceived significantly higher levels of informational and management continuity than patients with a non-acute clinical pathway, such as stable angina pectoris.…”

Putting analytics into action in care coordination research: Emerging issues and potential solutions

“…Coleman (2003) defines care transition as a set of tasks designed to ensure coordination and continuity of care as patients transfer from one facility to another. Care transition has been seen as an intervention tool that has a positive effect of lowering in-patient readmission rate and ED visits, while increasing the quality of life under many different medical conditions (Fisher et al, 2020;Kirkham et al, 2014;Kocher et al, 2013;Kowalkowski et al, 2019;Reeves et al, 2019;Stelfox et al, 2016;Takahashi et al, 2013). Coleman et al (2004) and Sato et al (2011) observe that care transitions can have varying patterns once patients are released from acute care hospitals.…”

“…Coordination is managed by teams of decision makers who have all the information about patients and make all care decisions. Several gaps exist in the literature; problems such as referral management (Bako et al, 2021), care transition management (Coleman et al, 2004;Fisher et al, 2020;Kirkham et al, 2014;Kowalkowski et al, 2019;Reeves et al, 2019;Stelfox et al, 2016;Takahashi et al, 2013), follow-up care management (Lynch et al, 2019), and disease management (Lee et al, 2020) need to be addressed in this perspective (see Supporting Information Table A.2). These problems are typically categorized as those that focus on coordination process management and those that focus on studying the effects of coordination intervention.…”