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Development and implementation of a transitions of care service in an
ambulatory care setting in collaboration with a primary care physician
Rachel J. Pucel, Pharm.D., CTTS, Michael J. Rush, Pharm.D., CDE, BCACP, CTTS, Karen L. Kier, Ph.D., M.Sc., R.Ph., BCPS, BCACP
 Transitions of care (TOC) from a hospital to primary
care physician's (PCP’s) office have been characterized
as “unsystematic, non-standardized, and fragmented.” 1
 Adverse drug events (ADEs) occurrence is the highest
when moving from one healthcare setting or provider
to another, which results in re-hospitalizations. 2
 Of the 20% of Medicare beneficiaries readmitted
within 30 days of discharge, an alarming 50% lacked a
PCP visit between hospitalizations. 3 This lack of
coordination and inadequate communication between
settings/providers need to be resolved in order to
reduce ADEs and readmission rates.
 Various models have been implemented and
documented utilizing hospital pharmacist’s performing
medication reconciliation, discharge counseling, and
coordination with outpatient follow-up. 4,5,6,7 However,
efforts need to be streamlined to the ambulatory care
setting to help ensure patients have appropriate
medication regimens and counseling following
discharge.
 Primary objective: To assess the impact of a
pharmacist-directed TOC clinic in a PCP setting to
reduce medication-related problems.
 Secondary objective: To assess interventions
recommended by the pharmacist and accepted in
collaboration with the PCP.
 ONU HealthWise is an interdisciplinary disease state
management and preventive medicine program.
 Ada Area Family Practice (AAFP) is a solo practitioner
family practice office located in rural Hardin county
that has a collaborative practice with ONU HealthWise.
 This TOC clinic will be a new service at AAFP.
 Inclusion: Established patients of AAFP, ≥18 yo,
recently discharged from the hospital
 Exclusion: Cognitively impaired without responsible
caregiver, or do not provide informed consent
 AAFP will receive notice of their established patient’s hospital discharge via
discharge summary sent from hospital and/or notification from patient.
 Prior to potential appointment, a pharmacist team member will provide initial
screening of hospital course focusing on reason for hospitalization, hospital
course, medications added, stopped or changed and medication-related
problems. (See After Hospital Care Plan to right)
 Medication-related problems include but are not limited to: duplicate
therapy, wrong drug/dose, medication indicated but not prescribed, lack of
indication, medication allergy, and adverse drug events.
 The pharmacist will utilize a modified version of Project BOOST’s 8P’s for risk
assessment to determine the extent of follow-up provided. (See chart below)
 To provide timely access to care, the office manager will schedule face-to-face
or phone follow-up appointments within 7 days of discharge in collaboration
with PCP.
Risk Assessment: 8P Screening tool
# of Problem Medications
 Anticoagulants, insulin, aspirin & clopidogrel
dual therapy, digoxin, narcotics
Psychological
Principal Diagnosis
 Heart failure, COPD, Pneumonia, Stroke,
Cancer
Polypharmacy- Number of Medications
Number of medication-related problems
screened for
Poor Health Literacy (inability to do TeachBack)
Patient Support (Absence of caregiver to assist
with discharge)
Prior Hospitalization/ ED visit
** This After
Hospital Care Plan
will be the chart
note used to
gather information,
identify
medication-related
problems, and
develop a plan for
each patient. It will
be kept with the
patient’s paper
chart in the
physician’s office.
High Risk = Face-to- Moderate Risk = Low Risk = No
face follow-up
Phone follow- up follow-up
≥1
0
0
Diagnosis or history No diagnosis or
of depression
history of
depression
Present
Not present
≥5
1+
1-4
0
No diagnosis or
history of
depression
Not present
0
0
Unknown until follow-up
No Caregiver
Caregiver/SelfCaregiver/Selfsufficient
sufficient
< 6 months
> 1 year
> 6 months – 1
year
Palliative Care
Participating in
No palliative care No palliative care
palliative care
indicated
indicated
** The highest category a patient falls in will determine the extent of follow-up that patient will receive.
 During the follow-up visit, the pharmacist will provide comprehensive
medication reconciliation, further identify medication-related problems,
determine the need to adjust medications, follow-up on test results, and order
additional monitoring in collaboration with PCP.
 Pharmacist will also provide education about patient’s disease states,
medications, importance of adherence, and self-management while providing
an updated, reconciled medication list to the patient, reinforcing changes in
the plan, and ensuring their next PCP appointment is scheduled.
 Patient demographics, summarized discharged information, number and type
of medication-related problems, number of interventions recommended, and
number of interventions accepted by the collaborating physician will be
documented.
 This study was approved by ONU’s Institutional Review Board.
 Enrollment in this study is ongoing. Since implementation
in November: 3 patients have been screened; 2 – highrisk and 1 – low-risk.
 Patient A: On 8 medications, 1 medication-related problem
– inaccurate medication list at PCP office, 1 intervention
recommended and 1 accepted
 Patient B: On 7 medications - 6 new, 5 medication-related
problems – treatment not optimal based on current
evidence (3), no indication for medication (1), adverse drug
event (1), 5 interventions recommended and 2 accepted
 Results are pending and will be submitted for publication.
1.
2.
3.
4.
National Quality Forum (NQF). Safe Practices for Better healthcare – 2010 Update: A consensus Report. Washington, DC: NQF; 2010.
Hume AL, Kirwin J, Bierber HL, et al. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012; 32: 326-37.
Jencks S, William M, Coleman E. Rehospitalizations among patients in the medicare fee-for service program. N Engl J Med. 2009;360;14:1418-28
Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150:
178-87.
5. Coleman EA, Parry C, Chalmers S, et al. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166: 1822-8.
6. Marusic S, Gojo-Tomic N, Erdeljic V, et al. The effect of pharmacotherapeutic counseling on readmissions and emergency department visits. Int J Clin Pharm
2013;35:37-44.
7. Schall M, Coleman E, Rutherford P, Taylor J. How-to guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable
Hospitalization. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org
Authors of this presentation have no known financial
or personal relationships with commercial entities that
may have a direct or indirect interest in the subject
matter of this presentation.