ABSTRACT
PURPOSE: The role of a care transition pharmacist (CTP) in a primary care resource center is described. SUMMARY: A CTP role was implemented as part of a primary care resource center team to provide medication therapy management services for patients at high risk for readmission, including patients with chronic obstructive pulmonary disease, with heart failure, or with complex medication regimens and taking more than nine medications. Patients were initially identified upon admission and were seen by the CTP who conducted a medication therapy review, provided patient education, and ensured that any medication-related issues were addressed before discharge. In addition, the CTP followed up with patients by telephone within 72 hours of discharge. CTP interventions included reinforcement of the plan of care (67%), medication-related interventions in which specific issues were addressed (9%), contacting of the physician for treatment plan clarification or care gap (9%), reinforced scheduling of the primary care physician follow-up appointment (8%), and referral of the patient to another caregiver (6%). Patients who received postdischarge follow-up from the CTP were significantly less likely to have an acute care visit within 30 days of discharge compared with patients not contacted by the CTP and had improved Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. CONCLUSION: Patients discharged from a community hospital who received a follow-up telephone call from a CTP were less likely to be admitted to the hospital or have an emergency department visit within 30 days of an acute care admission. HCAHPS patient satisfaction scores also improved in medication-related and discharge preparation question domains after CTP services were implemented.
