Key result
Pharmacist-led TCM linked to ~51% lower 30-day hospital readmissions versus no TCM.
Why the study?
Adherence to discharge instructions prevents 30-day hospital readmissions, and follow-up support by healthcare professionals may assist this, motivating an evaluation of pharmacist-led transition of care management on readmission rates in Medicare and Medicaid patients.
Does pharmacist-led Transition of Care Management reduce all-cause 30-day readmission rates in adult Medicare and Medicaid patients?
Observational
Does pharmacist-led Transition of Care Management reduce all-cause 30-day readmission rates in adult Medicare and Medicaid patients?
Absolute Event Rate: 16.9% vs 34.7%
p-value: p=0.008
Pharmacist-led transition of care management, including early post-discharge contact and medication reconciliation, significantly reduces 30-day hospital readmissions in Medicare and Medicaid patients.
Supports pharmacist-led TCM integration for CMS patients; leaves open need for RCTs to confirm causality and guide practice.
Introduction: A patient’s understanding, implementation of, and adherence to hospital discharge instructions are important in keeping them from being readmitted to the hospital within 30 days of discharge. The understanding of and ability to follow these instructions after the transition from hospital to home may be significantly supported by additional follow-up interactions by healthcare professionals. Programs supporting this crucial time in a patient’s health outcomes have been described as Transition of Care Management (TCM). This study evaluated the impact of pharmacist-led TCM on all-cause 30-day readmission rates among Medicare and Medicaid (CMS) patients. Methods: This retrospective chart review included adult CMS patients from a family medicine residency’s primary outpatient clinic who were admitted to area hospitals between August 2021 and December 2022. The pharmacy team attempted to provide TCM services 292 times. The team (pharmacist, pharmacy residents, and students) phoned the discharged patients within 48 hours to discuss discharge instructions and assistance needs, and to schedule a TCM appointment with the patient’s physician. The pharmacy team notified the interdisciplinary care team members to ensure comprehensive services would be provided. Data analysis examined three cohorts: those who were contacted and who received TCM, those who could not be reached, and those who were contacted but refused TCM services. The interventions were tracked and assessed together with patient readmissions. Subsequent evaluation compared those who received services to those who did not. Chi-square and descriptive statistics were applied to determine the result’s significance (p< .05). Logistic regression was conducted to investigate associations between receiving TCM and 30-day readmission while controlling for demographic variables. Results: Patients who received pharmacy-led TCM were less likely to be readmitted within 30 days of discharge (16.9%) than those who did not (34.7%, p = 0.008). The most common pharmacist interventions were medication reconciliations (98.5%, n = 140), medication education (80.3%, n = 114), and disease state education (43.6%, n = 62) During the medication reconciliation there were discrepancies noted among 79.6% of the encounters in the intervention group. Conclusion: Pharmacist-led TCM interventions and follow-up appointments significantly reduced 30-day readmission rates for adult CMS patients.
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Baccari et al. (2025) conducted an observational in Hospital discharge. Pharmacist-led Transition of Care Management (TCM) vs. No TCM services was evaluated on All-cause 30-day readmission (p=0.008). Pharmacist-led Transition of Care Management significantly reduced 30-day hospital readmission rates compared to no TCM services (16.9% vs 34.7%, p=0.008).
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