Transitions of Care Pharmacists Mitigate Readmission Rates for COPD

In the United States, chronic obstructive pulmonary disease (COPD) creates annual health care costs of $50 billion. The greatest proportion of this is attributed to the treatment of acute exacerbations of COPD (AECOPD), the third leading cause of hospital readmissions. The Centers for Medicare & Medicaid Services (CMS) includes AECOPD as 1 of the 6 conditions in the Hospital Readmissions Reduction Program (HRRP), signaling a significant focus on reducing this cause of readmission.¹

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High 30-day all-cause readmission rates incur up to a 3% payment penalty from CMS. This metric was a source of struggle for Lakeland Regional Health, a 910-bed not-for-profit teaching hospital in Florida. Its average fiscal year 2022 readmission rate was 23.7%, exceeding the 19.6% HRRP benchmark.²

To tackle this growing challenge, the institution created a model of integrated transitions of care (TOC) pharmacists with prescribing authority and evaluated the impact on all-cause 30-day readmission rates. The results, published in Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation, demonstrated a significant reduction in all-cause 30-day readmission rates between the pre- and postimplementation groups.²

TOC pharmacists play a crucial role in bridging the gap between different health care settings, such as hospitals, rehabilitation facilities, and patients’ homes. By meticulously reviewing medication regimens, reconciling discrepancies, and providing comprehensive education to patients and caregivers, they significantly reduce the likelihood of medication errors and adverse drug events during these vulnerable periods.³

This proactive approach directly benefits community pharmacists by ensuring patients arrive at their local pharmacies with accurate and up-to-date medication lists and a better understanding of their therapy. Consequently, community pharmacists can spend less time resolving confusion and more time providing essential patient care services, fostering stronger patient relationships and improving overall medication adherence in the long run.

The retrospective cohort study included all patients who met the criteria for the Medicare HRRP COPD model discharged between May 2021 and August 2023. The researchers included 187 patients and 92 patients in the pre- and postimplementation groups, respectively. The hospital-approved protocol, created in June 2022, granted TOC pharmacists prescribing authority for guideline-directed medical therapy (GDMT), consisting of a 30-day supply of rescue and triple-therapy inhalers, at discharge for patients with AECOPD. Readmission was counted if the patient was admitted to the study site within 30 days of discharge.²

The study results showed a significant relative risk reduction of 46% in the 30-day all-cause readmission rates. The researchers mitigated HRRP payment penalties by reducing the rate from 26% to 14%, well below the 19.6% HRRP benchmark. For readmissions due to AECOPD, the postimplementation group also had a lower readmission rate of 33%. This was not a statistically significant decrease, however, compared with the 61% rate of the preimplementation group.²

The proportion of patients discharged on GDMT also significantly increased from 26% to 100%. Medication access was a common treatment barrier, with 26% of patients in the postimplementation group unable to afford their inhalers. Pharmacists were meticulous in creating a regimen that considered cost, availability, and patient convenience.²

Importantly, additional pharmacist interventions were time-consuming, requiring multiple phone calls and hours of work. With 1 in 6 patients in the US with COPD reporting cost-related medication nonadherence, these actions were crucial for improving clinical outcomes and patient satisfaction. Providers may not have the time or capacity to perform these extra acts for each patient.²

This study’s findings further validate the significant impact of TOC pharmacists in reducing COPD readmissions and the importance of GDMT upon discharge. Pharmacists have the skill set to aid in patient care and relieve the burden on strained health care teams. TOC services are one of many areas where pharmacy models can improve patient outcomes, quality metrics, and hospital revenue.^4-6 Since this study’s completion, the institution has expanded its protocol with additional prescribing opportunities for TOC pharmacists and plans to expand services to non-HRRP patients.²

REFERENCES

1. Hospital Readmissions Reduction Program (HRRP). Centers for Medicare & Medicaid Services. Updated September 10, 2024. Accessed May 7, 2025. https://www.cms.gov/medicare/payment/prospective-paymentsystems/acute-inpatient-pps/hospital-readmissionsreduction-program-hrrp

2. Diaz AM, Smith LM, Peterson AN, Kent ML, Vellian NJ. Impact of pharmacist inhaler prescribing at discharge for chronic obstructive pulmonary disease on readmission rates. Chronic Obstr Pulm Dis. 2025;12(1):43-51. doi:10.15326/jcopdf.2024.0553

3. Bethishou L, Faggiano T, Shih N. The impact of pharmacist transitions of care interventions in identifying medications errors for patients discharged to a skilled nursing facility. Sr Care Pharm. 2025;40(5):203-208. doi:10.4140/TCP.n.2025.203

4. Dalton H, Hinely MT, Kostelic EM. Evaluation of the impact of a pharmacy transitions of care program. Am J Health Syst Pharm. 2024;81(7):e180-e185. doi:10.1093/ajhp.zxad306

5. March KL, Peters MJ, Finch CK, et al. Pharmacist transition-of-care services improve patient satisfaction and decrease hospital readmissions. J Pharm Pract.2022;35(1):86-93. doi:10.1177/0897190020958264

6. Nuckols TK, Berdahl CT, Henreid AJ, et al. Comprehensive pharmacist-led transitions-of-care medication management around hospital discharge adds modest cost relative to usual care: time-andmotion cost analysis. Inquiry. 2023;60:469580231218625.doi:10.1177/00469580231218625