(Management Case Study) Transitions of Care Gumbo: A Clinic-Hospital Collaboration to Improve Care Transitions in the Multivisit Patient

Purpose: The purpose of this session is to describe an ambulatory care clinic-community hospital collaborative model developed and implemented to improve care transitions for individuals with multiple recent admissions. Through the experience of this pharmacist-led TOC service, this session will demonstrate how one hospital addressed the rising burden of hospital readmission in a diverse patient population with multiple risk factors for readmission through collaboration with an external partner.

Methods: Recognizing the need for increased discharge support for patients with frequent hospital admissions and a need for additional resources to provide this support, a community hospital engaged a pharmacist-led clinic at a local college of pharmacy (COP). A pilot review of 20 patients was completed by the clinic to identify opportunities for outpatient intervention. The inpatient-outpatient collaborative model was informed by results of the pilot. The resulting service embedded a COP ambulatory care pharmacist within the hospital to work with hospital providers to identify and recruit eligible individuals 2.5 days per week. Eligible patients were those with two or more hospitalizations within the last year and/or heart failure (priority populations for the hospital) who were taking at least two medications and were discharging back into the community setting. The pharmacist met with participants by phone on approximately days 3-, 7-, 12-, and 28-days post-discharge to provide disease state management services, and a social worker contacted participants to address social determinants of health. Outcomes included comparison of 30-day and annualized admissions rates for individuals completing at least one outpatient visit (full participant) versus individuals who were unreachable (inpatient only). Participant demographics, adherence to the service protocol, and the number and types of completed interventions were assessed using descriptive statistics.

Results: The pilot demonstrated need for increased communication and identification of outpatient care barriers. From February 2022 to August 2023, 401 individuals (557 admissions) were reviewed. The assessed population of 106 participants were 60.8±14.3 years of age, 56.6% male, 63.2% black, and 36.8% white. Participants had an average of 2.3±2.0 admissions within the year prior to participation, 10.6±4.5 discharge diagnoses, and an average of 4.9±1.8 barriers to care at the time of enrollment. Participants who completed at least one outpatient visit (69.8%) had a 21.6% 30-day readmission rate versus 46.9% for those who received inpatient contact only (p=0.01, HR=0.31 (0.13-0.76)). Subgroup analyses demonstrated a lower 30-day readmission rate for full participants with multiple recent admissions (55.6% v. 22.9%; p=0.01) and a nonsignificant decrease in individuals with a heart failure diagnosis (n=40; 35.7% v. 19.2%; p=0.25). Annualized rate of admission was lower in full participants across all groups (p < 0.05). Over 2,000 interventions were documented, averaging 22.67 ± 18.2 per participant. Participants receiving “adherence and compliance” interventions were less likely to readmit within 30 days. Protocol adherence high, but discharge medication reconciliation and counseling had the lowest completion rate (39.6%) due to difficulties integrating into the established workflow. This did not impact readmission.

Conclusion: A pharmacist-led, telephone-based transitional care service collaboration between a college of pharmacy and community hospital improved 30-day readmission and annual admission rates in individuals at high risk for readmission. The success of the service has prompted its expansion to include additional patient populations. Opportunities for service improvement include modification of the current workflow to increase the completion of discharge medication reconciliation and counseling. This inpatient-outpatient collaborative model can be utilized in resource-limited settings to expand access to transitional care services.