Accountable Care in Transitions (ACTion): A Team-Based Approach to Reducing Hospital Utilization in a Patient-Centered Medical Home

Background: There is limited data describing the role of the patient-centered medical home (PCMH) in successful transitions programs and more information is needed to determine the transition points where pharmacist involvement is most impactful. Methods: A family medicine center developed a multidisciplinary outpatient-based transitions program focused on reducing emergency department (ED) and hospital use in medically complex patients. Key team members were a medical provider, clinical pharmacist practitioner (CPP), and care manager. The objective was to evaluate the impact of the program by comparing utilization before and after the intervention and to identify patient and process characteristic predictors of 30-day rehospitalizations. Results: Of the 268 patients included, the mean time to follow-up appointment attended was 11.6 (11.8) days after discharge. The majority of patients (72%) saw their primary care provider at follow-up. Patients experiencing the multidisciplinary intervention had lower 30-day rehospitalizations at 7, 14, and 30 days postdischarge with significance achieved at 14 and 30 days. Compared to before the intervention, reductions in both ED visits and hospitalizations as well as increases in clinic visits were seen at 1, 3, and 6 months. CPP involvement was associated with lower rehospitalizations (7.7% vs 18.8%; P = .04). Conclusion: A multidisciplinary outpatient-based transitions program embedded in the PCMH increased access to primary care and reduced hospital and ED utilization. Face-to-face CPP involvement significantly lowered rehospitalizations. This program describes a standardized approach to complex care needs with defined roles, a model that may be generalizable and reproduced in other medical homes.