(1347) Healthy Heart from Hospital to Home Transition of Care (ToC) Quality Assurance Project

Objectives: Transitions of care (TOC) gaps have been identified in the atrial fibrillation (AF) population, and community pharmacists have a unique opportunity to identify and address medication-related problems during the TOC from hospital to home. The primary objective was to determine the impact of a pharmacist and pharmacy-led AF TOC program. Outcomes assessed included: 30-day all-cause hospital readmission and ER visit rates measured by patient report, adherence, patient satisfaction, and pharmacist and pharmacy-led interventions.

Methods: This retrospective quality improvement initiative observed a structured community pharmacy TOC program for patients discharged with a diagnosis of AF. The program was conducted in partnership with a community hospital and the hospital’s on-site community pharmacy meds-to-beds service allowing for enhanced communication between inpatient and outpatient pharmacy teams and sharing of hospital discharge paperwork with the community pharmacy clinical services team. The program was offered to patients ≥18 years old with a diagnosis of AF identified by inpatient pharmacist. Eligible patients were communicated to on-site community pharmacy and the program was offered to patients through the meds-to-beds service. The TOC program included pharmacist-led outreach calls at days 3, 7-10 and 30 post-discharge. Day 3 included medication reconciliation, provider follow-up confirmation, and medication supply confirmation. Day 7-10 included a comprehensive medication review (CMR) and day 30 collected patient-reported outcomes including: hospital readmissions, ER visits, and perception of disease status. Pharmacist time for outreach was collected for each outreach time point. Enrollment into advanced adherence monitoring phase occurred following 7-10 day outreach completion and continued for 6 months to address any identified lapses in care through phone outreach. Patient satisfaction surveys were mailed following completion of the day 30 call. Patients were included if they did not opt-out of program prior to discharge or during day 3 post-discharge follow-up call. Exclusion criteria included: discharge to long-term care facility, skilled nursing facility, or other facility where patients did not manage their own medications. Patients who filled prescriptions outside of the community pharmacy providing the service were not included in the advanced adherence monitoring phase. Those who could not be reached after 3 attempts within 7 days at any point during the engagement phase were considered lost to follow-up. Enrollment in TOC program occurred from 8/1/2021 to 2/16/2023. Descriptive statistics were used to assess outcomes.

Results: Fifty-nine patients were included with 24 completing all three outreach calls. Mean age of the population was 71 years, 54% were male, and mean CHA2DS2-VASc score was 3.5. The 30-day all-cause readmission rate was 8.5% and no patients reported an ER visit. During the day 3 follow-up, 37.3% of patients had a medication discrepancy identified with a mean of 1.7 discrepancies per patient. Of 34 patients who were reached for the 7-10 day call, 88.2% had a CMR completed and 23.5% had a drug-related problem identified. Overall, there were 15 drug-related problems identified with eight categorized as adherence related. At the conclusion of the program, 87.5% of patients reported perception of their disease state status as “improved”. Overall, responses to the patient satisfaction survey were positive with 100% of respondents agreeing that they were pleased with the quality of care and services from their pharmacist and 75% agreeing that they would recommend this program to their friends and family. For patients who were reached, the mean time was 33 min for day 3, 70 minutes for day 7-10, and 37 min for day 30. Pharmacist preparation time for those that were not reached averaged approximately 11 minutes at each time point. Advanced adherence monitoring data collection is ongoing.

Conclusions: This community pharmacy AF TOC program identified and resolved medication discrepancies and drug-related problems in a high-risk population.