Impact of a transitions of care pilot service established by pharmacy residents within an academic medical center

Abstract Objectives The impact of a pharmacy postgraduate year two (PGY-2) resident-led transitions of care (TOC) pilot service targeting patients with chronic obstructive pulmonary disorder (COPD) and heart failure (HF) was evaluated through the primary objective of 30-day hospital readmissions at the University of Louisville Hospital (ULH). Secondarily, 30-day emergency department (ED) visits at ULH were assessed. Setting Urban academic teaching hospital Practice Description Prior to this pilot service, there were no formal TOC services for patients at high-risk of readmission at ULH. Practice Innovation The TOC pilot service providing coverage 16 hours per week included patients at least 18 years old admitted to a ULH internal medicine team with a primary or secondary diagnosis of COPD or HF. Patients planned to discharge to a location other than home or who could not be contacted following discharge were excluded. The service consisted of pharmacist-patient interactions prior to discharge, via telephone within 72 hours and in person seven to 14 days afterwards. Evaluation Data was collected via retrospective chart review from patients enrolled November 2017 to October 2018. For comparison, a computer-generated report identified patients that met criteria for the pilot service but were unable to be enrolled. Results Of the 23 patients enrolled in the TOC pilot service, zero required a hospital readmission to ULH within 30 days, compared to 12.3% for patients otherwise eligible. Similarly, zero patients enrolled in the TOC pilot service presented to the ED within 30 days of discharge, contrasted by 18.6% in the comparator group. Completion rates of the post-discharge follow-ups were 65.2% for the telephone call and 52.2% for the clinic visit. Conclusion PGY-2ambulatory care pharmacy residents implemented a new TOC service that contributed to lower rates of 30-day readmissions and ED visits compared to rates from patients otherwise eligible.