Pharmacist linkage in care transitions: From academic medical center to community

To improve the care of patients discharged from the University of Mississippi Medical Center (UMMC) after treatment for acute myocardial infarction, heart failure, pneumonia, and chronic obstructive pulmonary disease; reduce preventable hospital readmissions; and inform future care transition collaborations between hospital teams and community pharmacies. Study was conducted at UMMC, UMMC outpatient pharmacies, and targeted community pharmacies. UMMC is the state’s only academic health science center, providing all levels of care. Participants were at UMMC’s 722-bed hospital in Jackson, MS. Participating pharmacies included 2 UMMC outpatient pharmacies and community pharmacy research partner sites within 60 miles of UMMC. A pharmacist transitions coordinator (PTC) worked with inpatient and community-based pharmacists to provide predischarge medication reconciliation and 30 days of medications on discharge. The PTC with access to inpatient and outpatient records facilitated communication among settings/providers. Community pharmacists provided telephonic and face-to-face medication therapy management (MTM). The project was structured as a prospective, randomized controlled trial of pharmacist-led care coordination during transition from inpatient to community setting, with follow-up MTM by community pharmacists. In this intention-to-treat analysis, readmission rates were assessed with propensity adjustment. Drug therapy problems (DTPs) identified/resolved were assessed and reported through descriptive statistics. Ninety-six patients were enrolled. Positive outcomes in overall reduced readmission rates were observed in the intervention group at 30, 60, 90, and 180 days, although statistical significance was not achieved because of limited enrollment. Approximately 60% participated in MTM postdischarge, with 453 interventions and 169 DTPs identified and addressed (98% > 1 DTP; 20% > 5 DTPs). Implementation experience includes PTC successes, new partnerships, and connectivity among all providers, as well as enrollment challenges, follow-up, and service delivery timeframe. With access to patient records, pharmacists have the potential to positively affect patient outcomes through medication management during care transitions.