Magazine article Drug Topics

The Pharmacist's Role in Transitions of Care

Magazine article Drug Topics

The Pharmacist's Role in Transitions of Care

Article excerpt


During my rotation at a hospital in the Alameda Health System (AHS), in Oakland, Calif., I worked with the Care Transitions Team funded by the Gordon and Betty Moore Foundation (CTT), composed of a pharmacist, nurse case managers, and social workers, who partner with other healthcare providers to help reduce hospital réadmissions. Members of this particular patient population have compounded social and medical problems that put them at higher risk for réadmissions connected with their chronic obstructive pulmonary disease (COPD), HIV, and congestive heart Mure.

The innovative efforts of a transitional care pharmacist (TCP) help manage these patients. The pharmacist's role was to make sure that upon their return home, patients would continue to take their medications appropriately, as prescribed by their physicians.

The program

In 2012, AHS joined the California-based initiative Avoid Réadmissions through Collaboration (ARC), with the goal of reducing 30-day and 90-day réadmissions through implementation of the PROJECT RED model, which includes a 12-step standardized approach to discharge planning and discharge education.

Early evidence shows promising declines in readmission rates resulting from the work of the CTT. For CTT patients admitted to the hospital from October 2012 to April 2013, there was a 39% reduction in 30-day réadmissions (from 23% to 14%) and a 59% reduction in 90-day réadmissions (56% to 23%) compared to the high-risk readmission rates occurring before the start of the CTT.

With the imposed penalty fee set by the Centers for Medicare and Medicaid Services (CMS) for readmission rates deemed excessive, the work of the CTT comes at a crucial time. The current penalty fee, 1 % of every Medicare payment, is based on readmission rates for acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN). Beginning in 2014, the penalty will increase to 2%, and it is likely that in 2015 other conditions, such as stroke and COPD, will be added to the list of conditions. According to CMS, within 30 days of discharge 20% of Medicare patients are readmitted to the hospital because of medication errors that occur during patients' transitions between healthcare facilities and their homes. …

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