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. 2023 Jul-Aug;63(4):1230-1236.e1.
doi: 10.1016/j.japh.2023.04.008. Epub 2023 Apr 17.

Impact of an Area Agency on Aging pharmacist-led Community Care Transition Initiative

Antoinette B Coe, Brigid E Rowell, Paige A Whittaker, Andy T Ross, Kim T L Nguyen, Nathaniel Bergman, Karen B Farris

Impact of an Area Agency on Aging pharmacist-led Community Care Transition Initiative

Antoinette B Coe et al. J Am Pharm Assoc (2003). 2023 Jul-Aug.

Abstract

Background: Rural older adults are at risk of readmissions and medication-related problems after hospital discharge.

Objectives: This study aimed to compare 30-day hospital readmissions between participants and nonparticipants and describe medication therapy problems (MTPs) and barriers to care, self-management, and social needs among participants.

Practice description: The Michigan Region VII Area Agency on Aging (AAA) Community Care Transition Initiative (CCTI) for rural older adults after hospitalization.

Practice innovation: Eligible AAA CCTI participants were identified by an AAA community health worker (CHW) trained as a pharmacy technician. Eligibility criteria were Medicare insurance; diagnoses at risk of readmission; length of stay, acuity of admission, comorbidities, and emergency department visits score more than 4; and discharge to home from January 2018 to December 2019. The AAA CCTI included a CHW home visit, telehealth pharmacist comprehensive medication review (CMR), and follow-up for up to 1 year.

Evaluation methods: A retrospective cohort study examined the primary outcomes of 30-day hospital readmissions and MTPs, categorized by the Pharmacy Quality Alliance MTP Framework. Primary care provider (PCP) visit completion, barriers to self-management, health, and social needs were collected. Descriptive statistics, Mann-Whitney U, and chi-square analyses were used.

Results: Of 825 eligible discharges, 477 (57.8%) enrolled in the AAA CCTI; differences in 30-day readmissions between participants and nonparticipants were not statistically significant (11.5% vs. 16.1%, P = 0.07). More than one-third of participants (34.6%) completed their PCP visit within 7 days. MTPs were identified in 76.1% of the pharmacist visits (mean MTP 2.1 [SD 1.4]). Adherence (38.2%) and safety-related (32.0%) MTPs were common. Physical health and financial issues were barriers to self-management.

Conclusion: AAA CCTI participants did not have lower hospital readmission rates. The AAA CCTI identified and addressed barriers to self-management and MTPs in participants after the care transition home. Community-based, patient-centered strategies to improve medication use and meet rural adults' health and social needs after care transitions are warranted.

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Conflict of interest statement

Disclosure: The authors declare no relevant conflicts of interest or financial relationships.

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