Care Transitions in COPD Patients: The Pharmacist is Calling

Program featuring care transition pharmacists shown to reduce hospital readmissions, improve patient satisfaction.

Several quality-monitoring organizations stress the need for American health care providers to improve care transitions. Incomplete or inefficient handoffs are often directly responsible for medical errors or set the stage for poor outcomes. Most organizations are actively looking for ways to improve care continuity and coordination. In an article that appears in the September 15, 2014, issue of the American Journal of Health-System Pharmacy, a team of pharmacists from Pennsylvania describes a process involving pharmacists that decreased hospital readmissions and emergency department visits. The process targeted patients at high risk for readmission: patients with chronic obstructive pulmonary disease (COPD), with heart failure, or who were prescribed complex medication regimens or more than 9 medications. Of these patients, 83% had COPD.

The team developed a multidisciplinary care pathway for COPD patients hospitalized with acute exacerbations, and the pathway stipulated care transition pharmacist (CTP) involvement. Consultation with the CTP benefited COPD patients in several ways. The CTP promoted smoking cessation, spirometry testing, and immunization, and also reviewed inhaler technique.

Researchers assigned a CTP to patients designated high risk upon admission. The CTP provided medication therapy management for patients (N = 175), educated these patients, and resolved medication-related issues throughout their hospitalization. Within 3 days of discharge, the CTP telephoned patients to field questions, identify problems, assess medication adherence, and reinforce teaching.

Approximately two-thirds of all patients needed reinforcement concerning their care plan. Of the patients, 9% had medication-related problems that the CTP resolved. For 8% of patients, the CTP reinforced the need to visit the primary care physician for follow-up. The CTP referred 6% of patients to another caregiver.

Among patients whom the CTP was able to contact post-discharge (n = 118), acute care visits within 30 days of discharge were significantly less likely compared with patients who could not be contacted (n = 57). Readmission was also significantly less likely. Patients who received CTP services were considerably more likely to be satisfied with their care as measured by a validated satisfaction tool.

The authors describe challenges they encountered during the planning and implementation of this care process. They stress that pharmacists who wish to implement similar programs need to be able to demonstrate their value to administrators in advance.