MANAGEMENT OF COMPLEX CARDIOVASCULAR PATIENTS IN A PHARMACIST-RUN TRANSITIONS OF CARE CLINIC

BACKGROUND/OBJECTIVE: Hospital readmissions in the United States, especially in patients at high-risk, cost more than $17 billion annually. Although care transitions is an important area of research, data are limited regarding its efficacy, especially among rural patients. In this study, we describe a novel transitions-of-care clinic (TOCC) to reduce 30-day readmissions in a Veterans Health Administration setting that serves a high proportion of rural veterans. METHODS: In this quality improvement initiative we conducted a pre-post study evaluating clinical outcomes in adult patients at high risk for 30-day readmission (Care Assessment Needs score > 85) discharged from the Iowa City Veterans Affairs (ICVA) Health Care System from 2017 to 2020. The ICVA serves 184,000 veterans across 50 counties in eastern Iowa, western Illinois, and northern Missouri, with more than 60% of these patients residing in rural areas. We implemented a multidisciplinary TOCC to provide in-person or virtual follow-up to high-risk veterans after hospital discharge. The main purpose of this study was to assess how TOCC follow-up impacted the monthly 30-day patient readmission rate. RESULTS: The TOCC resulted in a 19.2% relative reduction in 30-day readmission rates in the 12-month postimplementation period compared to the preimplementation period (9.2% vs 11.4%, P = .04). Virtual visits were more popular than in-person visits among both urban and rural veterans. There was no difference in outcomes between these two follow-up options, and both groups had reduced readmission rates compared to non-TOCC follow-up. CONCLUSIONS: A multidisciplinary TOCC within the ICVA featuring both virtual and in-person visits reduced the 30-day readmission rate. This reduction was particularly notable among patients with congestive heart failure.

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Provider and health care team member insights for implementing a transitions of care clinic in a federally qualified health center

Journal of the American Pharmacists Association ◽

10.1016/j.japh.2019.01.020 ◽

2019 ◽

Vol 59 (4) ◽

pp. S12-S18.e1

Author(s):

Brock T. Davis ◽

Lynn M. Thoma ◽

Ashley H. Meredith

Keyword(s):

Health Care ◽

Health Center ◽

Team Member ◽

Health Care Team ◽

Care Team ◽

Transitions Of Care ◽

Care Clinic ◽

Federally Qualified Health Center

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Project EVADE: Evaluating the effects of a pharmacist-run transitions of care clinic on hospital readmissions

Journal of the American Pharmacists Association ◽

10.1016/j.japh.2019.11.012 ◽

2020 ◽

Vol 60 (3) ◽

pp. 503-508

Author(s):

Morgan S. Brauner ◽

Mallory L. Accursi ◽

Steffany L. Cantillo ◽

Michael V. Baxter ◽

Christopher J. Burant

Keyword(s):

Hospital Readmissions ◽

Transitions Of Care ◽

Care Clinic

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Abstract TP306: The Problem With Transitions: An Evaluation of Appointment Compliance in the Transition of Care Clinic

Stroke ◽

10.1161/str.51.suppl_1.tp306 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Brittany A Young ◽

Fawad Yousuf ◽

Sadia Waheed ◽

Jessica Lee

Keyword(s):

Acute Stroke ◽

Transitional Care ◽

Recurrent Stroke ◽

Stroke Care ◽

Transitions Of Care ◽

Acute Stroke Care ◽

Care Clinic ◽

Stroke Treatment ◽

Appointment Adherence

Background: Stroke is the fifth leading cause of death in the US and a leading cost of disability. The National Transitions of Care (TOC) Coalition has developed a conceptual model of transitional care that defines TOC as an efficient transfer, verification, and clarification of information between communicating providers. The TOC model assumes that, not only are providers accountable in communicating and receiving pertinent information, but most important, that patients and families are engaged throughout the process. Post-stroke treatment non-adherence may impact morbidity and mortality, hospital readmission rates, recurrent stroke risk, and may lead to decreased quality of life. To improve post-acute stroke care, we developed an Advance Practice Provider (APP) driven Stroke TOC Clinic at our institution. We sought to compare rates of appointment adherence in this clinic with that of previously routine 90 day follow up, hypothesizing that a sooner appointment would be associated with greater appointment adherence, given the acuity of the diagnosis of stroke. Methods: A single center retrospective chart review was conducted for all stroke patients who were discharged home and scheduled for an appointment in the TOC Clinic between June 1, 2018 to August 31, 2018. TOC appointments were scheduled within 3-14 days. Adherence rates were compared to routine 90-day follow-up visits between March 1, 2014 to June 30, 2014. Results: During the study period, 143 patients were offered a TOC follow-up appointment. Each patient was contacted, via phone, within 48 hours of hospital discharge by an APP. 58% of patients (n=83) completed appointments; whereas, 24.5% (n=35) no-showed, and 17.5% (n=25) declined/cancelled the appointment. Compared to the 2014 routine stroke follow-up patients, 58% (n=204) completed appointments; whereas, 32% (n=113) no-showed, and 10% (n=36) declined/cancelled the appointment. Conclusions: The results were contrary to the hypothesis. No show rates were not different between the 2018 TOC follow-up group as compared to the 2014 routine follow-up group. The study is ongoing by evaluating other factors that may affect show rates (ie patient gender, geographic location, and insurance status) and how this affects post-acute stroke care.

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