Impact of an interprofessional transition of care service on 30-day hospital reutilizations

Quality Improvement Intervention Using Social Prescribing at Discharge in a University Hospital in France: Quasi-Experimental Study

BACKGROUND

Social prescription is seen as a public health intervention tool with the potential to mitigate social determinants of health. On one side, social prescription is not yet well developed in France, where social workers usually attend to social needs, and historically, there is a deep divide between the health and social sectors. On the other side, discharge coordination is gaining attention in France as a critical tool to improve the quality of care, assessed indirectly using unplanned rehospitalization rates.

OBJECTIVE

This study aims to combine social prescription and discharge coordination to assess the need for social prescription and its effect on unplanned rehospitalization rates.

METHODS

We conducted a quasi-experimental study in two departments of medicine in a French university hospital in a disadvantaged suburb of Paris over 2 years (October 2019-October 2021). A discharge coordinator screened patients for social prescribing needs and provided services on the spot or referred the patient to the appropriate service when needed. The primary outcome was the description of the services delivered by the discharge coordinator and of its process, as well as the characteristics of the patients in terms of social needs. The secondary outcome was the comparison of unplanned rehospitalization rates after data chaining.

RESULTS

A total of 223 patients were included in the intervention arm, with recruitment being disrupted by the COVID-19 pandemic. More than two-thirds of patients (n=154, 69.1%) needed help understanding discharge information. Slightly less than half of the patients (n=98, 43.9%) seen by the discharge coordinator needed social prescribing, encompassing language, housing, health literacy, and financial issues. The social prescribing covered a large range of services, categorized into finding a general practitioner or private sector nurse, including language-matching; referral to a social worker; referral to nongovernmental organization or group activities; support for transportation issues; support for health-related administrative procedures; and support for additional appointments with nonmedical clinicians. All supports were delivered in a highly personalized way. Ethnic data collection was not legally permitted, but for 81% (n=182) of the patients, French was not the mother tongue. After data chaining, rehospitalization rates were compared between 203 patients who received the intervention (n=5, 3.1%) versus 2095 patients who did not (n=51, 2.6%), and there was no statistical difference.

CONCLUSIONS

First, our study revealed the breadth of patient's unmet social needs in our university hospital, which caters to an area where the immigrant population is high. The study also revealed the complexity of the discharge coordinator's work, who provided highly personalized support and managed to gain trust. Hospital discharge could be used in France as an opportunity in disadvantaged settings. Eventually, indicators other than the rehospitalization rate should be devised to evaluate the effect of social prescribing and discharge coordination.

Evaluation of the Impact of Discharge Clinic Follow-Up Interventions on 30-Day Readmission Rates

Care transition programs can result in cost avoidance and decreased resource utilization. This project aimed to determine whether implementation of a discharge clinic, referral to a community paramedicine program, or a second postdischarge call affected 30-day readmission rates. This single-center retrospective exploratory design study included 727 discharged patients without access to a primary care provider who were scheduled for a discharge clinic transitions appointment. Readmission rates were 17.7% for those who completed a discharge appointment and 24.7% for those who did not; 4% for those completing a second postdischarge call and 26% for those who did not; and 11.1% for those referred to a community paramedicine program and 24.9% for those not referred. A completed discharge clinic appointment resulted in 36% lower odds of readmission. A completed discharge clinic appointment was effective in reducing 30-day readmission rates as was a follow-up call.

Effect of pharmacy-led interventions during care transitions on patient hospital readmission: A systematic review

BACKGROUND

The Centers for Medicare and Medicaid (CMS) established the Hospital Readmissions Reduction Program (HRRP) to reduce reimbursement payments to hospitals with excessive patient readmissions. Because of this program, hospitals have developed transitions of care (TOC) programs to improve patient outcomes.

OBJECTIVES

To identify and uniformly summarize the impact of pharmacy-led TOC interventions on 30-day readmission rates since the implementation of CMS HRRP.

METHODS

This study followed an a-priori protocol that was registered to International Prospective Register of Systematic Reviews. A systematic search was conducted using PubMed, EMBASE, International Pharmaceutical Abstracts, and CINAHL from January 1, 2013 through January 14, 2022. Studies were included if they met the following criteria: pharmacy-led intervention, 30-day readmission outcomes, patients at least 18 years old, original research performed in the United States, and English language only articles. Descriptive statistics were used to summarize study characteristics, outcomes, and elements of the study interventions.

RESULTS

A total of 1964 abstracts were screened with 123 studies being included in the review. A total of 110 (89.4%) studies showed a decrease in readmission rates. The largest decrease in readmission rates was 44.5% (range 0.2%-44.5%, median = 7.4%) and the most common pharmacy-led intervention was patient counseling (n = 119, 96.7%) followed by medication reconciliation (n = 111, 90.2%). High-risk patient populations were commonly targeted with 52 studies (42.3%) focusing on CMS HRRP related diagnoses.

CONCLUSION

Most pharmacist-led TOC interventions contributed to lower rates of 30-day readmission. Future studies should investigate the types of interventions that most significantly impact readmission rates.

The impact of an interprofessional care transitions clinic on readmission rates and costs

The objective of this study was to assess the effectiveness of the Interprofessional Care Transitions Clinic (ICTC) in reducing preventable readmissions and their associated costs among Medicare/Medicaid patients. A prospective cohort study was conducted among adults who were discharged from the University of Maryland Prince George's Hospital Center to assess the comparative effectiveness of a clinic-based intervention in terms of readmission events, potentially avoidable utilization, length of stay, and hospital charges. Outcomes were evaluated at 1 month, 3 months, and 6 months post-discharge. There were statistically significant differences in the following outcomes (follow-up period): proportion of readmissions (3 months), potentially avoidable utilization (1 month), and mean medical charges for ICTC patients compared to non-ICTC patients (1 month). This program was aimed at testing the impact of having an interprofessional team focused on providing holistic patient-centered care.

Potential to Decrease Hospital Readmission Reduction Program Penalty Through Pharmacist Discharge Visits

SUMMARY

Nurses and Pharmaceutical Care: Interprofessional, Evidence-Based Working to Improve Patient Care and Outcomes

Pharmaceutical care necessitates significant efforts from patients, informal caregivers, the interprofessional team of health care professionals and health care system administrators. Collaboration, mutual respect and agreement amongst all stakeholders regarding responsibilities throughout the complex process of pharmaceutical care is needed before patients can take full advantage of modern medicine. Based on the literature and policy documents, in this position paper, we reflect on opportunities for integrated evidence-based pharmaceutical care to improve care quality and patient outcomes from a nursing perspective. Despite the consensus that interprofessional collaboration is essential, in clinical practice, research, education and policy-making challenges are often not addressed interprofessionally. This paper concludes with specific advises to move towards the implementation of more interprofessional, evidence-based pharmaceutical care.

Impact of a pharmacist-led substance use disorder transitions of care clinic on postdischarge medication treatment retention

BACKGROUND

The Veterans Health Administration (VHA) has made significant improvements in increasing prescribing of medication treatment for opioid use disorder (MOUD) and medication treatment for alcohol use disorder (MAUD); however, several barriers to treatment retention remain. In an effort to improve MOUD/MAUD retention, a Veterans Affairs (VA) facility established a pharmacist-led substance use disorder (SUD) transitions of care telephone clinic for patients discharged from an inpatient hospitalization on MOUD/MAUD, including buprenorphine/naloxone (BUP/NAL) and extended-release (ER) naltrexone injections. Pharmacists within the clinic assess aspects of treatment retention such as medication tolerability, perceived barriers to continuing treatment, status of current prescriptions, and appointment coordination.

OBJECTIVES

The primary objective of this study was to evaluate the impact of a pharmacist-led SUD transitions of care telephone clinic on MOUD/MAUD retention following inpatient initiation in patients with opioid use disorder (OUD) and/or alcohol use disorder (AUD). Secondary objectives included subanalyses of clinic impact on MOUD/MAUD retention based on study medication or diagnoses, health care utilization, and characterization of pharmacist interventions.

METHODS

The study identified patients for inclusion from inpatient units at a VA hospital. The study included patients if they were >18 years of age, had a diagnosis of AUD and/or OUD, and were initiated on ER naltrexone or BUP/NAL during admission and continued at discharge from August 1, 2018, to December 31, 2019. The study excluded patients if they declined clinic involvement, transferred facilities, moved beyond the VA catchment area, or were unable to be reached for initial contact after 3 telephone attempts. The intervention group included patients enrolled in the pharmacist-led SUD transitions of care telephone clinic, while the control group included patients initiated on MOUD/MAUD during admission who were eligible but not referred for clinic enrollment.

RESULTS/CONCLUSIONS

The study identified a total of 150 patients for inclusion (n = 54 intervention group; n = 96 control group). The study observed a statistically significant difference for the primary endpoint of combined 1- and 3-month MOUD/MAUD retention rates as measured by a continuous, multiple-interval measure of medication acquisition (CMA) of ER naltrexone and BUP/NAL for the intervention group vs. control group (1-month: 77.3% vs. 56.8%, p = 0.004; 3-month: 71.4% vs. 48%, p = 0.0002). When analyzed by study medication, we also observed a statistically significant improvement in continuous use of ER naltrexone for those enrolled in the clinic (1-month: 71.4% vs. 45.9%, p = 0.01; 3-month: 66.7% vs. 34.4%, p = 0.0003). The study did not observe any statistically significant improvements for BUP/NAL (1-month: 87.1% vs. 75.8%, p = 0.13; 3-month: 79.4% vs. 68.5%, p = 0.24) or establishment with a BUP/NAL clinic (90.5% vs. 80% patients established, p = 0.46). Likewise, the study did not observe any statistically significant differences for combined emergency department (ED) visits (1-month: 24.1% vs.17.1% patients with ED visit, p = 0.40; 3-month: 31.5% vs. 29.2% patients with ED visit, p = 0.85) or hospitalizations (1-month: 9.3% vs. 14.6% re-hospitalization, p = 0.45; 3-month: 14.8% vs. 26% re-hospitalization, p = 0.15) for those in the intervention group vs. the control group. Overall, the study observed statistically and clinically significant improvements in MOUD/MAUD retention rates for patients enrolled in a pharmacist-led SUD transitions of care telephone clinic.

Refining interprofessional, outpatient transitions of care services to reduce hospital readmissions

RATIONALE, AIMS AND OBJECTIVES

Transitions of care between healthcare facilities are associated with increased risk of adverse events and hospital readmissions. Previous studies employing pharmacists in transitions of care showed reduced 30-day readmissions, however, many were without an active comparator. There is no standardized approach to pharmacist involvement in transitions of care services, making it difficult to ascertain where pharmacist expertise is most meaningful. This paper aims to compare the 30-day hospital readmissions between an interprofessional hospital discharge visit (iHDV) with physician and pharmacist involvement to a non-interprofessional HDV (PHDV) without pharmacist involvement.

METHOD

This was a retrospective quality improvement initiative examining patients of two outpatient clinical practices within a large, academic medical centre. The primary analysis compared 30-day hospital readmission rates for patients with a scheduled PHDV or iHDV within 30-days of index hospital discharge date, regardless of attendance at the HDV. The secondary outcome compared 30-day hospital readmission rates for patients who completed a PHDV or iHDV. Primary and secondary outcomes were evaluated using bivariate analysis and multivariate analysis by stepwise logistic regression, for both intention-to-treat (ITT) and per protocol (PP).

RESULTS

This study found significantly lower 30-day hospital readmissions for patients scheduled for a PHDV compared to an iHDV (16.7% vs 21.5%, P = .0230) in an unadjusted analysis, but no significant difference in adjusted analyses (P = .4856). Per-protocol analysis found no significant difference in 30-day hospital readmission rates between groups in unadjusted and adjusted analyses. Visit completion rates were significantly different between groups, with approximately twice as many PHDV group patients completing visits as compared to the iHDV group (74.1% vs 61.5%, P < .0001).

CONCLUSION

This study demonstrates an interprofessional clinic visit employing a clinical pharmacist in the post-hospital discharge visit did not significantly reduce 30-day hospital readmission rates compared to a post-hospital discharge visit without pharmacist involvement.

The Role of the Nurse in the Management of Medicines During Transitional Care: A Systematic Review

PURPOSE

To synthesise knowledge and to explore the role of the nurse in medicines management during transitional care.

METHODS

An integrative systematic review was conducted. Electronic databases such as PubMed [including Medline], Web of Knowledge, Scopus, and Cinahl from January 2010 to April 2020 were searched. Original qualitative and quantitative studies written in English that focused on the role of the nurse in medicines management during transitional care, which included movement between short-term, long-term, and community healthcare settings were included.

RESULTS

The search process led to the retrieval of 10 studies, which were published in English from 2014 to 2020. They focused on the role of the nurse in patients' medicines management during transitional care in various healthcare settings. Given variations in the aims and methods of selected studies, the review findings were presented narratively utilizing three categories developed by the authors. In the first category as 'medication reconciliation process' the nurse participated in obtaining medication history, performing medication review, identifying medication discrepancies, joint medication reconciliation and adjustment. The second category as 'collaboration with other healthcare providers' highlighted the nurses' role in clarifying medicines' concerns, interdisciplinary communication and consultation, discharge planning and monitoring. In the third category as 'provision of support to healthcare recipients', the nurse was responsible for interpersonal communication with patients, education about medicines, and simplification of medication regimens, and symptoms management during transitional care.

CONCLUSION

Nurses play a crucial role in the safety of medicines management during transitional care. Therefore, they should be empowered and more involved in medicines management initiatives in the healthcare system. Patient safety and avoidance of medication errors during transitional care require that medicines management becomes a multidisciplinary collaboration with effective communication between healthcare providers.

Interprofessional 30-day readmission review novel curriculum

Planning and coordination among health-care professionals decrease readmission rates, yet workers have few opportunities to learn interprofessionally to improve transitions of care. An interprofessional readmission review curriculum engaged medical residents, pharmacy residents, nurse practitioner students, early-career nurses, and social work students in a critical analysis of readmissions. Learners (N = 98) participated in a 2 h, collaborative learning session to review health records from a patient readmitted within 30 days of discharge and determine plausible root causes for readmissions. A 5-item post-session survey completed by 83 (85%) evaluated knowledge and perceived competencies in transitions of care before and after participation. Significant improvements (p < .001) occurred in ratings for all five items. Two open-ended questions captured learners' perceptions of understanding and appreciating the roles of other disciplines in the discharge process and importance of interprofessional communication. Several themes emerged including understanding gaps in the discharge process, improving interprofessional collaboration and communication, and paying more attention to discharge documentation. This innovative program helped build essential skills to ensure safe discharges by introducing learners to interprofessional perspectives in analyzing root causes for readmissions, strategies to improve discharge planning, and the value of team-based care.

Evolution of Interdisciplinary Transition of Care Services in a Primary Care Organization

Transitions of care create complex management challenges for providers and leave patients vulnerable to medication errors and hospital readmissions. This article examines the evolution of an interdisciplinary team of pharmacists and nurse care managers and their impact on safe and effective transitions from the acute care settings back into primary care. This article explores successes and challenges of this primary-care-based clinic in managing patients safely through often-complex situations, and explores future directions for improving care processes and outcomes.

Description of a transitions of care and telemedicine simulation lab activity

BACKGROUND AND PURPOSE

Transitions of Care (ToC) is an important clinical practice area requiring trained health care professionals, but there is limited literature describing ToC in the didactic curriculum. The purpose of this study was to describe and evaluate a ToC telemedicine simulation activity in a doctor of pharmacy curriculum.

EDUCATIONAL ACTIVITY AND SETTING

A one-hour lecture and simulation activity was incorporated into a second-year course. Student teams participated in discharge and telemedicine encounters with standardized patients (SPs). Six medication-related problems (MRPs) were incorporated into the activity. Activity documents were collected to identify student competency.

FINDINGS

Fifty-nine student pharmacists in 16 teams participated. All teams accurately identified five of the six MRPs. Fourteen teams (87.5%) accurately identified the sixth MRP after completion of the telemedicine encounter. Six teams (62.5%) completed the discharge medication list accurately and completely. All teams provided medication education, and 93.8% (n = 15) of teams identified follow-up was needed. Ten teams utilized effective interview sequence and structure during both encounters. Activity challenges included resources, financial support and SP training.

SUMMARY

Case-based learning and the use of simulation has good evidence supporting its use in education. Utilizing these techniques to reinforce concepts may be a beneficial way for students to be trained effectively to deliver impactful ToC services.