Impact of Pharmacy Student-Driven Postdischarge Telephone Calls on Heart Failure Hospital Readmission Rates: A Pilot Program

Impact of a Managed Care Elective on Pharmacy students' Confidence Performing Transitions of Care via Telehealth

BACKGROUND

With rising costs to the US healthcare system, managed care has become a vital component to cost containment and improved patient care. Pharmacy education provides a solid foundation in clinical and administrative sciences. However, managed care principles have not been widely and universally incorporated into the pharmacy curricula.

OBJECTIVE

To evaluate the impact of a novel elective course in managed care topics on pharmacy students' perceived understanding and confidence to deliver transitions of care (TOC) services via telehealth (i.e. telephonically).

METHODS

This cohort study employed a sequential three-module based managed care elective course within a pharmacy curriculum. In module one, students received didactic lectures on managed care pharmacy and navigating electronic health records (EHR). In modules two and three, students engaged telephonically with real patients, who were referred to pharmacy faculty from collaborating physician offices through an online cloud based EHR, to perform Comprehensive Medication Reviews (CMR), Targeted Medication Reviews (TMR), and TOC consultations. The primary outcome was students' perceived understanding and confidence in performing TOC services via a survey pre- and post-elective course. A calculation of of 30-day hospital readmissions rates conducted by comparing patients who received these services versus those who did not is also described in this report.

RESULTS

Students demonstrated a statistical improvement in perceived understanding and confidence in performing TOC services post-elective course across a total range of 17 survey questions (p<0.05). Incidentally, 11.8 % of patients who were contacted and completed a call with students had a 30-d readmission compared to a previously reported national benchmark.

CONCLUSIONS

Education in managed care and providing pharmacy students the opportunity to practice telehealth strategies for services commonly performed in pharmacy practice, such as TOC, are of value in the pharmacy curriculum to prepare students for the growth in digital health and expanding opportunities outside of traditional community and hospital settings.

The Impact of Pharmacists on Telehealth During Transitions of Care: A Literature Review

Purpose: To provide a review of pharmacists' impact during transitions of care (TOC) visits utilizing telehealth. Methods: An electronic literature review was conducted on studies that addressed pharmacists' impact on telehealth during TOC. Articles included in the review were randomized or observational studies, cohort studies, case series or case reports, literature reviews, or pilot studies conducted on adults. Articles investigating children were excluded from the review. Results: Of the articles identified, 14 studies met the eligibility criteria and were selected for the literature review. All of the studies were published in English between 2013 and 2021. Most were conducted in the United States of America (n = 12) with 1 conducted in Ireland (n = 1) and 1 in Australia (n = 1). The majority of telehealth monitoring was conducted via phone (n = 8), video conferencing (n = 3), or both (n = 2) in patients' homes by pharmacists alone (n = 8) while the remaining studies involved telemonitoring by a combination of pharmacy fellows, residents, and/or students. These findings showed that pharmacist intervention in patient care showed improved patient outcomes and goal markers for a variety of health conditions as well as lower rates of 30 day, 60 day, and 90 day hospital readmissions. Conclusion: Pharmacist involvement in telehealth monitoring had a positive impact on TOC interventions and overall patient outcomes including decreased hospital readmissions and increased patient medication adherence.

Pharmacist-Led Deprescribing for Patients With Polypharmacy and Chronic Disease States: A Retrospective Cohort Study

Background: Current literature and practice have demonstrated that pharmacists have an integral role in deprescribing. However, research regarding their impact on patients with chronic diseases is limited. Objective: To assess the impact of a pharmacist-led intervention on deprescribing inappropriate medication for patients with chronic diseases within a four-month study period compared to patients receiving usual care. Methods: This study was conducted at NYU Langone Health. Patients of the intervention group were referred by a provider and met the criteria of polypharmacy, required chronic disease states management, were nonadherent to medications, had poor health literacy, or required titration for heart failure (HF) guideline directed medical therapy. Results: A total of 142 patients were reviewed over a two-year period. At the end of the study period, the median number of medications for the two respective groups was similar (11 [4 - 30] vs 11 [2 - 23]). The pharmacist-led intervention had on average one medication deprescribed (m = -1.00, sd = 2.57), whereas the control group had on average .44 additional medications (m = 0.44, sd = 3.32) prescribed. Furthermore, the intervention group presented statistically significant differences (P = 0.046) regarding their diastolic blood pressure after the pharmacists' intervention (m = 72.69, sd = 11.64). Most importantly, patients with HF presented statistically significant improvement in their ejection fractions after the intervention (m = 41.46%, sd = 19.28%). Conclusion: The pharmacist-led intervention resulted in significant discontinuation of medications for patients in the intervention group compared to those in the usual care group within four-months.

A Scoping Review of Student Pharmacist-Led Transitions-of-Care Initiatives

OBJECTIVES

To identify and evaluate the current literature pertaining to student pharmacist-led transitions-of-care (TOC) initiatives and to inform pharmacy educators regarding the current and future roles of pharmacy learners in TOC.

FINDINGS

A total of 14 articles were identified describing student-led initiatives in care transitions to the inpatient setting and from the inpatient to the outpatient setting. In most studies, student pharmacists involved in delivering TOC services were completing either an advanced pharmacy practice experience or an introductory pharmacy practice experience and were most commonly performing services such as admission medication history and reconciliation. The studies evaluated the impact of student-led TOC services through the identification or resolution of medication-related problems, interventions, and/or discrepancies and included limited and conflicting results pertaining to patient care-based outcomes.

SUMMARY

Student pharmacists are involved in delivering and leading a variety of TOC services in the inpatient setting and postdischarge period. These student-led TOC initiatives not only provide added value to patient care and the health system but also enhance students' preparation and readiness for pharmacy practice. Colleges and schools of pharmacy should incorporate learning experiences into the curriculum that equip students to contribute to TOC efforts and promote continuity of care across the health system.

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.

Student-Led discharge counseling program for High-Risk medications in a teaching hospital in Saudi Arabia: A pilot study

Discharge counseling by pharmacists reduces adverse medication events, emergency department visits, and readmissions. Studies indicate that pharmacy students in advanced pharmacy practice experiences (APPE) can deliver effective medication-related activities. An open label randomized controlled trial was conducted in adults discharged on warfarin, insulin, or both. Pharmacy students performed medication reconciliation, structured medication counseling, and follow-up calls 72-hours post-discharge. The usual care arm received traditional education. The primary outcome was the 30-day readmission rate post-discharge. Ninety-eight patients on high-risk medications were randomized to intervention (n = 51) or usual care (n = 47). The 30-day hospital readmission rate was lower in the intervention group (8/51, 15% vs. 11/47, 23%); (p = 0.48). There was no statistical difference in the time to first unplanned health care use (hazard ratio = 0.49 (95 %CI, 0.19–1.24), or the time-to-first clinic visit post-discharge (p = 0.94) between the two arms. Students identified 26 drug-related problems during reconciliation. Patients in the intervention arm reported high satisfaction with the service (mean 3.94; SD 0.11). Involving APPE students in the transition of care activities presents an excellent opportunity to minimize pharmacists' workload while maintaining patient care services.

Improving 30-day readmissions: Student pharmacists' role in transitions of care

BACKGROUND

Pharmacists have reduced 30-day hospital readmissions when involved with transitions of care (TOC). The impact of student pharmacists on readmissions is more limited.

OBJECTIVE

The goal of this study was to describe student pharmacists' role in a new TOC service and determine their impact on 30-day hospital readmissions.

METHODS

We designed a 3-step TOC service spanning inpatient, discharge, and follow-up led by student pharmacists and involving both inpatient and ambulatory care pharmacy preceptors. The student pharmacists followed inpatient care and discussed medications with the patients. Discharge orders were reviewed, and the student pharmacists provided discharge education. On discharge, the student pharmacists wrote a handoff to the ambulatory care pharmacist describing inpatient care, discharge medication list, follow-up, and unresolved medication issues. Finally, the student pharmacists participated in the outpatient follow-up at the primary care provider office with the provider and an ambulatory care pharmacist. Readmissions were compared between this process and a standard-of-care historical control group using chi-square analysis.

RESULTS

The student pharmacist-led TOC service reduced 30-day hospital readmissions by 13.1% (P = 0.018) compared with standard of care.

CONCLUSION

Student pharmacists are effective members of the health care team in reducing readmissions. Student pharmacists are cost-effective, appropriately trained, and well positioned to assist with these services.

Transitional Care Interventions for Patients with Heart Failure: An Integrative Review

Heart failure (HF) is a life-limiting illness and presents as a gradual functional decline with intermittent episodes of acute deterioration and some recovery. In addition, HF often occurs in conjunction with other chronic diseases, resulting in complex comorbidities. Hospital readmissions for HF, including emergency department (ED) visits, are considered preventable. Majority of the patients with HF are often discharged early in the recovery period with inadequate self-care instructions. To address these issues, transitional care interventions have been implemented with the common objective of reducing the rate of hospital readmission, including ED visits. However, there is a lack of evidence regarding the benefits and adverse effects of transitional care interventions on clinical outcomes and patient-related outcomes of patients with HF. This integrative review aims to identify the components of transitional care interventions and the effectiveness of these interventions in improving health outcomes of patients with HF. Five databases were searched from January 2000 to December 2019, and 25 articles were included.

Effectiveness of Mobile Phone-Based Interventions for Improving Health Outcomes in Patients with Chronic Heart Failure: A Systematic Review and Meta-Analysis

Mobile phone-based interventions are increasingly used to prevent adverse health outcomes in heart failure patients. However, the effects of mobile phone-based interventions on the health outcomes of heart failure patients remain unclear. Our review aims to synthesize the randomized controlled trials (RCT) of mobile phone-based interventions for heart failure patients and identify the intervention features that are most effective. Electronic searches of RCTs published from January 2000 to July 2019 were conducted. Primary outcomes included all-cause mortality, readmission, emergency department visits, length of hospital stays, and quality of life. Secondary outcomes were self-care behaviors, including medication adherence and other clinical outcomes. A total of eight studies with varying methodological quality met the inclusion criteria and were analyzed. Voice call intervention was more frequently used compared with telemonitoring and short message services. Our meta-analysis showed that voice call interventions had significant effects on the length of hospital stays. However, no significant effects on all-cause mortality, readmission, emergency department visits, or quality of life were found. Compared to other mobile phone-based interventions, voice calls were more effective in reducing the length of hospital stay. Future studies are needed to identify which features of mobile phone-based intervention most effectively improve health outcomes.

Usefulness of a Nurse-Led Program of Care for Management of Patients with Chronic Heart Failure

BACKGROUND The aims of the present study were to determine whether a nurse-led program of care can improve medication adherence, quality of life (QoL), rates of rehospitalization, and all-cause mortality for chronic heart failure (CHF) patients. MATERIAL AND METHODS CHF patients were randomly assigned into either a control group or an intervention group. At 12 weeks, patients were followed up to evaluate the rate of medication adherence, QoL (as assessed by SF-12 physical and mental component score [PCS and MCS]), rehospitalization, and all-cause mortality. RESULTS We recruited 152 patients. No significant differences in demographics, comorbidities, CHF severity, or etiology at baseline were observed. At discharge, no significant differences in medications prescription, PCS (46 vs. 45), or MCS (55 vs. 56) were observed. However, at 12-week follow-up, compared to the control group, patients in the intervention group were more likely to keep on medications therapy, with a significantly higher use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker [73.8% vs. 59.7%], beta-blocker (62.5% vs. 51.4%), and aldosterone receptor antagonist (60% vs. 54.2%). Both PCS (35 vs. 40) and MCS (42 vs. 49) were also significantly lower in the control group versus the intervention groups (P<0.05). Patients in the control group had higher incident rate of rehospitalization (8.0% vs. 5.2% per person-week) than in the intervention group, with an incident rate ratio of 1.54 (95% confidence interval [CI]: 1.06-2.23). CONCLUSIONS A nurse-led discharge program of care can be a cost-effective and feasible approach for management of CHF patients in China.

Feasibility and performance of a patient-oriented discharge instruction tool for heart failure

Background

The provision of patient-centred discharge instructions is a pivotal goal for improving quality of care for patients with heart failure (HF) during care transitions. We tested the feasibility and performance of a novel discharge instruction tool co-designed with patients and adapted for HF; the patient-oriented discharge summary (PODS-HF) with the aim of improving communication, comprehension and adherence to discharge instructions.

Methods

An iterative process was used to adapt and implement an existing patient instruction tool for patients with HF (PODS-HF). A mixed methods approach was then used to explore patient experience, feasibility and performance using a pre–post study design among eligible patients admitted for HF over a 6-month period. Outcome measures included: the documentation of patient-centred instructions, a locally derived Average Discharge Score (ADS) based on the inclusion of instructions in nine key areas, patient satisfaction and understanding and adherence to instructions at 72 hours and 30 days determined using follow-up phone calls.

Results

19 patients were enrolled. The ADS increased by 68% with more consistent documentation. Patient satisfaction remained high. Patients provided PODS-HF reported receiving written information about HF related signs and symptoms to watch for (two out of five patients in the usual care group vs seven out of seven patients in the PODS-HF group; p=0.045). Patients also felt more confident to manage their own health and 30-day adherence to diet and exercise instructions improved while reducing the need for unscheduled visits. Quantitative results were supported by themes identified during follow-up calls, namely, the utility of written instructions and the importance of a follow-up call.

Conclusion

PODS-HF is a feasible tool for the delivery of patient-centred discharge instructions for patients with HF. The individual benefits of clarification and reinforcement made during follow-up calls among patients receiving this tool remains to be clarified.