Development of a collaborative transitions-of-care program for heart failure patients

PURPOSE: The development and implementation of a pharmacy-led transitions-of-care program to reduce the risk of readmission and increase satisfaction for heart failure (HF) patients are described. SUMMARY: A transitions-of-care committee was established at Providence St. Peter Hospital, a 390-bed community teaching facility in Olympia, Washington, and focused on implementing standardized workflow processes for conducting admission medication review and discharge medication review and providing discharge counseling for patients with HF. All HF patients were to have admission medication reconciliation performed within 48 hours of admission. All HF patients were assigned a readmission risk complexity score after being admitted to the medical floor. The pharmacist, resident, and student performed daily patient medication profile reviews on all HF patients to ensure the use of optimal doses of appropriate HF medication regimens. The pharmacist proactively monitored for patient discharges using reports available in the electronic medical record. The pharmacist, resident, student, or HF nurse navigator counseled each patient on the discharge medications and answered any questions or addressed concerns regarding medications. Input from the quality-improvement specialist and data abstracter was used to ensure compliance with HF core measures. The program has resulted in an increase in core measure compliance and a reduction of HF, 30-day, and all-cause readmissions, and patient satisfaction scores have improved. For each avoided readmission, there was an associated decrease of $5652 in variable costs. CONCLUSION: The implementation of a pharmacy-led transitions-of-care program improved patient care by prioritizing those who needed medication reconciliation and led to increases in HF core measure compliance and patient satisfaction scores.