Pharmacy Resident Transition of Care Program Reduces Heart Failure Readmissions


Heart failure is a "revolving door" problem for hospitals.

Heart failure (HF) is a “revolving door” problem for hospitals.

Once admitted initially, HF patients often become familiar to hospital staff, as they are ordinarily readmitted over and over again. In fact, 1 of every 6 HF patients is readmitted within 30 days.

HF-related readmission is not only a clinical conundrum, but also a financial issue. The US Centers for Medicaid and Medicare Services reduce payments to certain hospitals with excess 30-day readmissions related to HF.

Clinical pharmacists from Jackson Memorial Hospital in Miami, Florida, recently published a study that examined how an HF transition of care (TOC) service run by a pharmacy resident might affect patient care. By including medication therapy optimization, HF patient education, and discharge and follow-up facilitation, this TOC service actually decreased readmission rates.

A pharmacy resident designed and conducted this 6-month prospective pilot study with a goal to decrease readmission rates among HF patients. At the start of the study, Jackson Memorial Hospital’s 30-day readmission rate was 28.1%—slightly above the national average, Medicare reported.

The pharmacy resident identified patients through emergency department admission reports and direct requests from discharge nurses. The participants had an average of roughly 3 admissions annually and had been discharged with an average of 8.5 medications. About half of them lacked health insurance.

After enrollment, the pharmacy resident provided the 30 participants with tailored medication and disease state counseling, assistance in ensuring they had all discharge medications, and follow-up calls for appointment reminders and further counseling.

As a result of the pharmacy resident-run TOC service, the hospital’s 30-day HF readmission rate decreased to 16.6%, with the majority of patients attending scheduled follow-up appointments after discharge. Four patients were readmitted once, though half of them for reasons unrelated to HF. Two patients were readmitted twice, though 1 was readmitted both times for reasons unrelated to HF.

Although small, this study showed how a single pharmacy resident’s efforts can help interdisciplinary teams and HF patients achieve modest goals.

The study appeared in the supplement to the June 2015 issue of the American Journal of Health-System Pharmacists.

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