Implementation of a Pharmacist-Led Transitions of Care Program within a Primary Care Practice: A Two-Phase Pilot Study

Abstract

Pharmacists in primary care settings have unique opportunities to address the causes of ineffective care transitions. The objective of this study is to describe the implementation of a multifaceted pharmacist transitions of care (TOC) intervention integrated into a primary care practice and evaluate the effectiveness of the program. This was a two-phase pilot study describing the development, testing, and evaluation of the TOC program. In Phase 1, the TOC intervention was implemented in a general patient population, while Phase 2 focused the intervention on high-risk patients. The two pilot phases were compared to each other (Phase 1 vs. Phase 2) and to a historical control group of patients who received usual care prior to the intervention (Phase 1 and Phase 2 vs. control). The study included 138 patients in the intervention group (Phase 1: 101 and Phase 2: 37) and 118 controls. At baseline, controls had a significantly lower LACE index, shorter length of stay, and a lower number of medications at discharge, indicating less medical complexity. A total of 344 recommendations were provided over both phases, approximately 80% of which were accepted. In adjusted models, there were no significant differences in 30-day all-cause readmissions between Phase 2 and controls (aOR 0.78; 95% CI 0.21-2.89; p = 0.71) or Phase 1 (aOR 0.99; 95% CI 0.30-3.37; p = 0.99). This study successfully implemented a pharmacist-led TOC intervention within a primary care setting using a two-phase pilot design. More robust studies are needed in order to identify TOC interventions that reduce healthcare utilization in a cost-effective manner.

Keywords: pilot study; primary care; readmissions; transitions of care.

Figure A1

Referral Process for Pharmacy Transition of Care Consult for Phase 1 (February to May 2018 and Phase 2 (October 2018 to May 2019) (Abb. TOC, transitions of care; RN, registered nurse; LPN, licensed practical nurse; PCP, primary care provider; CPT, current procedural terminology; CPC+, comprehensive primary care plus; CABG, coronary artery bypass grafting; TAVR, transcatheter aortic valve replacement).