Pharmacy-led optimization of transitions of care in patients with heart failure

IntroductionEffective transitional care for patients with heart failure is essential to ensure optimal utilization of guideline-directed medical therapy. Clinical pharmacists and specially trained pharmacy technicians have unique skillsets that enable them to improve care transitions.ObjectivesTo evaluate the implementation of a comprehensive pharmacy transitions of care program in an acute heart failure population.MethodsA retrospective, single center, single-arm study evaluating pharmacy-delivered transitions of care services (admission and discharge medication reconciliation, medication cost assessment, medication counseling, bedside delivery of discharge medications, and post-discharge phone calls) for patients discharged from the heart failure service. The primary outcome was the completion rate of transitions of care services. Secondary outcomes included the medication intervention rate and types of interventions made, medication classes assessed for cost, discharge medication prescription captured, and 30-day all-cause readmissions.ResultsFive hundred and ninety-five patients were eligible for the transitions of care program. Admission and discharge medication reconciliations were completed in 68.1% and 92.1% of patients, respectively. Medication cost assessments were completed for 39.8% of patients. Heart failure medication counseling prior to discharge was completed for 83.9% of patients. Discharge prescription capture rate was 56.5% and bedside prescription delivery was provided for 27.8% of patients. The discharge medication reconciliation intervention rate was 37.4%, with the most common intervention being dose adjustment. Post-discharge outreach was conducted for 229 patients, with education provided for 69.4% and an intervention rate of 43.7%. The 30-day all-cause readmission rate was lower for patients on the heart failure service compared with the institution (10.1% vs 16.5%).ConclusionHigh rates of completion and utilization were identified after the implementation of a comprehensive pharmacy transitions of care program. Utilization of clinical pharmacists and pharmacy technicians during transitions of care improved medication access, patient education, and reduced medication-related problems.