Advances in Geriatrics

A Pharmacist-Led Transitional Care Program to Reduce Hospital Readmissions in Older Adults

Fed Pract. 2018 December;35(12):42-50

References

1. Vincent GK, Velkoff VA. The Next Four Decades: The Older Population in the United States: 2010 to 2050. US Department of Commerce, Economics and Statistics Administration, US Census Bureau; 2010.

2. Merle L, Laroche ML, Dantoine T, Charmes JP. Predicting and preventing adverse drug reactions in the very old. Drugs Aging. 2005;22(5):375-392.

3. Shi S, Mörike K, Klotz U. The clinical implications of ageing for rational drug therapy. Eur J Clin Pharmacol. 2008;64(2):183-199.

4. Coleman EA, Min Sj, Chomiak A, Kramer AM. Posthospital care transitions: patterns, complications, and risk identification. Health Serv Res. 2004;39(5):1449-1465.

5. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513-1516.

6. Price Waterhouse Coopers Health Research Institute. The Price of Excess: Identifying Waste in Healthcare Spending. Price Waterhouse Coopers Health Research Institute; 2008.

7. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.

8. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-167.

9. Paquin AM, Salow M, Rudolph JL. Pharmacist calls to older adults with cognitive difficulties after discharge in a Tertiary Veterans Administration Medical Center: a quality improvement program. J Am Geriatr Soc. 2015;63(3):571-577.

10. The American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-2246.

11. Greenwald JL, Halasyamani L, Greene J, et al. Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps. J Hosp Med. 2010;5(8):477-485.

12. Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72-83.

13. Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini‐cog: a cognitive ‘vital signs’ measure for dementia screening in multi‐lingual elderly. Int J Geriatr Psychiatry. 2000;15(11):1021-1027.

14. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45(6):613-619.

15. Chaves PH, Semba RD, Leng SX, et al. Impact of anemia and cardiovascular disease on frailty status of community-dwelling older women: the Women’s Health and Aging Studies I and II. J Gerontol A Biol Sci Med Sci. 2005;60(6):729-735.

16. Fried LP, Tangen CM, Walston J, et al; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-M156.

17. Walston J, McBurnie MA, Newman A, et al; Cardiovascular Health Study. Frailty and activation of the inflammation and coagulation systems with and without clinical comorbidities: results from the Cardiovascular Health Study. Arch Int Med. 2002;162(20):2333-2341.

18. Stookey JD, Purser JL, Pieper CF, Cohen HJ. Plasma hypertonicity: another marker of frailty? J Am Geriatr Soc. 2004;52(8):1313-1320.

19. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci. 2007;62(7):722-727.

20. Pugh JA, Wang CP, Espinoza SE, et al. Influence of frailty‐related diagnoses, high‐risk prescribing in elderly adults, and primary care use on readmissions in fewer than 30 days for veterans aged 65 and older. J Am Geriatr Soc. 2014;62(2):291-298.

21. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-834.

22. Mekonnen AB, McLachlan AJ, Brien JA. Pharmacy‐led medication reconciliation programmes at hospital transitions: a systematic review and meta‐analysis. J Clin Pharm Ther. 2016;41(2):128-144.

23. Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Int Med. 2006;166(9):955-964.

24. Gleason KM, McDaniel MR, Feinglass J, et al. Results of the Medications at Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med. 2010;25(5):441-447.

25. Haynes KT, Oberne A, Cawthon C, Kripalani S. Pharmacists’ recommendations to improve care transitions. Ann Pharmacother. 2012;46(9):1152-1159.

26. Khanna R, Wachsberg K, Marouni A, Feinglass J, Williams MV, Wayne DB. The association between night or weekend admission and hospitalization‐relevant patient outcomes. J Hosp Med. 2011;6(1):10-14.

Patients were excluded if they were expected to be discharged to any facility where the patient and/or the caregiver were not primarily responsible for medication administration after discharge. Patients who met eligibility criteria but were not seen by the transitional program pharmacist (due to staff capacity) were included in this analysis as a convenience comparison group of patients who received usual care. Patients were not randomized. All communication occurred in English, but this project did not exclude patients with limited English proficiency.

A program support assistant conducted the daily query of the hospital database. The pharmacist conducted the chart review to determine eligibility and delivered the intervention. Eligible patients were selected at random for the intervention with the intention of providing the intervention to as many veterans as possible.

The GMED Intervention

The GMED program included 2 phases, which were both conducted by a CPS with oversight from a senior CPS with geriatric pharmacology expertise and an internist/geriatrician.

The CPS carrying out the transitional care program was involved in the planning and design of the project and met weekly with the geriatrician. The Figure provides an overview of the intervention.

The first phase of the transitional care program included an individual, face-to-face meeting between the CPS and the patient during the hospitalization. If a veteran was not present in the room at the time of an attempted visit, the pharmacist made 2 additional attempts (3 total) to include the patient in the transitional care program during the hospitalization.

The CPS performed medication reconciliation and provided medication education regarding administration and usage of the patient’s medications, using an open-ended format.¹¹ The caregiver, if any, was included in the discussion either at the bedside or by telephone following the face-to-face visit with the patient. The CPS communicated recommendations regarding appropriateness of therapy (including any potential barriers to medication adherence) to the medical team (including the attending, resident[s], and interns) in person or by telephone and through documentation in the CPRS.

The recommendations were based on the clinical expertise of the CPS as well as on guidelines for prescribing in older adults.^10,12 The CPS used a checklist to ensure all components of the intervention were completed (Appendices 1 and 2).

The second component of the transitional care program included a telephone visit within 2 to 3 days of discharge, conducted by the same CPS who performed the face-to-face visit. The purpose of the telephone visit was to perform medication reconciliation, identify and rectify medication errors, provide further patient education, and assist in facilitating appropriate follow-up by the patient’s primary care provider (PCP), if required. At a minimum, veterans were asked a series of questions pertaining to their concerns about medication regimens, receipt of newly prescribed medications at discharge, additional education regarding medications after the CPS encounter during hospitalization, and whether the veteran required assistance with the medication regimen in the home setting. Follow-up questions were asked as needed to clarify and identify potential medication problems. All information from this telephone encounter was communicated to the PCP through CPRS documentation and by telephone as needed.