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Nursing & Health Sciences Research Journal

Abstract

Introduction: This quality improvement project assessed the impact of a newly implemented transitions of care (TOC) pharmacist service at a large health system. The service involves a comprehensive review of recently discharged value-based care individuals, including chart review and, when necessary, telephonic follow-up by the pharmacist 3-6 days post-discharge.

Methods: This retrospective evaluation compared two groups: pre-implementation (September 1st, 2023 - January 30th, 2024) and post- implementation (March 1st, 2024 - July 30th, 2024) of TOC pharmacist service, focused on patient evaluations 3-6 days post-discharge. The primary outcome was a composite of 30-day re-hospitalization rates including urgent care, emergency department, hospital, and observation visits. Secondary outcomes included a composite of 90-day re-hospitalization rates, serious and non-serious medication interventions, and the number of medication-related problems identified.

Results: A total of 155 individuals were included per group. The composite 30-day rehospitalization rate was 9% (14/155) in the pre-implementation versus 14% (22/155) in the post-implementation, p = 0.26. There was a higher percentage of composite 90- day re-hospitalization in the pre-implementation at 23% (35/155) vs. 11% (17/155), p = 0.01 and of 90-day emergency department and urgent care visits at 14% (22/155) vs. 6.5% (10/155), p = 0.025. A higher proportion of individuals required pharmacist intervention for non-serious medication issues in the post-implementation at 15% (23/155) versus 5.2% (8/155) in the pre-implementation, p = 0.01.

Discussion: Although there was no statistically significant difference in composite 30- day re-admission rates between the groups, there was a lower proportion of individuals re-admitted within 90 days in the post-implementation, suggesting many individuals required pharmacist intervention.

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