Description of Home-Based Medication Therapy Management Services in an Interprofessional Transitional Care Program Aimed at Reducing 30-Day Hospital Readmissions

Purpose: Since the establishment of the Hospital Readmission Reduction Program (HRRP) in 2012, preventing 30-day unplanned hospital readmissions is crucial for reimbursement by Centers for Medicare & Medicaid Services. Published reports have shown pharmacist interventions after hospital discharge are associated with a smaller incidence of medication errors 30 days after hospital discharge, but most of these reports include pharmacists making follow-up phone calls. No published reports have described home-based pharmacy services as a part of transitional care programs designed to reduce unplanned 30-day hospital readmissions. This project describes the inclusion of a pharmacist as a part of an interprofessional transitional care team. Methods: Safe Transitions for the Elderly Patient (STEP) is a transitional care program for Medicaid-eligible adults at least 50 years of age who have been recently discharged from the hospital in Tarrant County, TX. Enrolled patients receive an intake home visit from a medical provider within the first 72 hours after discharge which includes referral to other STEP providers (e.g. pharmacists, physical therapists and social workers). Patients on high-risk medications, who are believed to be non-adherent to medications or need short-term medication management were referred to the pharmacist (0.3FTE) for home-based medication therapy management (MTM) services. All patient encounters are documented in an electronic health record (EHR). Risk stratification scores were calculated by including the total sum of each the following parameters: problem meds, psychiatry, polypharmacy, health literacy, patient support, prior hospitalization, and palliative care. High risk stratification scores were defined as those with 5 having or more risk factors. Descriptive statistics were used to characterize the study population. Pearson’s chi-square was used to examine the association between categorical variables. Results with a p value less than .05 were considered statistically significant. Patients enrolled in the STEP program during the time pharmacists provided services were included in this analysis (August 2014 to January 2015 and October 2015 to July 2016). Results: A total of 366 patients were enrolled in STEP during the specified time frame with 79 being seen by the pharmacist. The mean ages in those who were and were not seen by the pharmacist were 63.4 years (range 50-92) and 66.5 years (range 50-98), respectively (p=0.02). The majority of the patients seen by the pharmacist were women (72%, n=57), which was not significantly different than those not seen by the pharmacist (p=0.44). The median number of medications in those who were and were not seen by the pharmacist were 15 (range 3-38) and 11 (range 1-32), respectively (p=0.0002). Of the patients seen by the pharmacist who reported race/ethnicity, 35.4% identified as Black or African American (n=28). The proportion of all STEP patients with calculated risk stratification score was 93% (n=342). The proportion of patients with high risk stratification scores for those who were and were not seen by the pharmacist were 49% and 57%, respectively (p=0.22). The most common discharge diagnoses for patients seen by the pharmacist were heart failure and COPD exacerbations. Hospital readmission rates were not found to be significantly different in those who were seen by the pharmacist versus those who did not (10%, 14%, p=0.34). Conclusions: Hospital readmission rates were not found to be significantly different between those patients who were seen by a pharmacist as part of a home-based interprofessional transitional care team versus those who were not. Overall hospital readmission rates were low for both groups. In this program, patients who saw the pharmacist were more likely to be younger and be taking more medications than those who did not see the pharmacist. Patients who saw the pharmacist did not have significantly higher risk stratification scores than those patients who did not see the pharmacist. More research is needed to demonstrate the benefit of home-based pharmacy transitional care services.