Readmission Rates Associated with Pharmacist Involvement in a Geriatric Transitional Care Management Clinic.

OBJECTIVE

To evaluate the impact of a post-discharge pharmacist telephone call on 30- and 90- day readmission rates as part of a transitional care management (TCM) service in a geriatric patient-centered medical home (PCMH).

METHODS

Adults 60 years of age and older who had established primary care at the PCMH for at least one year and were discharged from the hospital between 7/1/2013 and 2/21/2016 were included. Readmission rates for patients who received and did not receive a pharmacist TCM phone call were compared. Secondary data analysis was conducted between individuals who received all three components of the service compared with those who received on a nurse navigator plus primary care provider (PCP) visit.

RESULTS

Among 513 discharges of unique patients (mean age, 80.4 years; women 63%), 269 (52.4%) received a pharmacist phone call. Readmission rates at 30 days were 8.9% for patients who received a pharmacist TCM phone call compared to 12.7% for those who did not receive this service (OR 0.67 [95% CI, 0.38-1.18; P=0.17]). When comparing only those individuals who received all three components of the service (pharmacist, nurse navigator, and PCP) (n=215) compared to those who received only a nurse navigator plus PCP visit (n=66), there was no difference in 30-day readmission rates (7.9% vs. 10.6%, p=0.49). However, there were significantly fewer readmissions within 90-days (16.3% vs. 31.8%, p=0.01).

CONCLUSION

Pharmacist phone calls as part of an interdisciplinary TCM service did not result in a statistically significant difference regarding readmission rates at 30 days; however, patients who received all three components of the service had significantly fewer readmissions at 90 days, compared to patients who did not speak with a pharmacist but did complete a visit with a nurse navigator and physician. Future research is needed to determine which patients may benefit the most from this service and to identify strategies to increase patient participation.