Impact of Pharmacist-Driven Heart Failure in-Home Counseling on 30-Day Readmission Rates.

PURPOSE/OBJECTIVE: This study examines the impact of a pharmacist-driven intervention specific to heart failure patients with the goal of reducing readmission rates and improving quality of life in this population. FINDINGS/CONCLUSIONS: A total of 21 patients were included in the study. Twelve patients were female and 9 were male. The mean age was 76 years with a range of 65-93 years. Two of the 21 patients were readmitted within 30 days. One of the 2 readmitted patients died soon after admission was in the final stages of his or her disease and passed away soon after; it is unlikely for a home visit to have altered their path. This study did not meet the goal sample size due to some unforeseen limitations. However, the limited data that were obtained suggest a strong basis for further research. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: During a patient's transition in care from hospital to home, he or she is most vulnerable for complications and readmission. Intervention during this time will not only improve patient care and quality of life but also contribute to a notable cost savings for each prevented readmission. Pharmacist intervention, as part of the health care team, during this tenuous time has shown to make a valuable impact.

Excellence in Population Health: A Successful Community-Based Care Transitions Program Model.

PURPOSE/OBJECTIVE: The Community-based Care Transitions Program (CCTP) defined a broad spectrum of interventions and services for elderly patients at high risk of hospital readmission. The purposes for a CCTP as developed by the Centers for Medicare & Medicaid Services are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk beneficiaries, and to document measurable savings. The goals for this CCTP initiative were as follows: achievement of a 20% reduction in the 30-day all-cause readmission rate across all partner hospitals compared with baseline; reduction in the 30-day all-cause readmission rate among the high-risk cohort served; and achievement of the target volumes for full enrollment. PRIMARY PRACTICE SETTINGS: The partnership included acute care institutions and community-based care organizations that have been involved with care transition programs for years and have a long history of working collaboratively to provide services to a largely low-income, underserved, and ethnically and racially diverse target population. FINDINGS/CONCLUSIONS: The program successfully transitioned to full operation within the first year of inception. To date, the partnership of the acute hospital setting and the community-based organizations has reached and provided services to nearly 8,000 total individuals, surpassing our target enrollment goal. To date, the readmission rate has decreased to 12.5%, which is an 11% decline since inception of the program. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The collaboration of health care providers, social workers, nurse practitioners, physicians, community pharmacists, and the visiting nurses is integral to a successful transition from hospital to home. Home visits by the transition facilitators allowed for the coordination of a multitude of services in the community, including those previously available to patients in the past that have rarely been accessed. Including a pharmacist on the team provided teaching regarding medication adherence, medication management, and pharmacy services, which added to interventions to decrease future hospitalizations.