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Open AccessArticle

Implementation of a Pharmacist-Led Transitions of Care Program within a Primary Care Practice: A Two-Phase Pilot Study

Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA
Department of Epidemiology and Environment Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY 14214, USA
General Physicians, P.C., Buffalo, NY 14214, USA
Authors to whom correspondence should be addressed.
Pharmacy 2020, 8(1), 4;
Received: 21 November 2019 / Revised: 19 December 2019 / Accepted: 31 December 2019 / Published: 4 January 2020
(This article belongs to the Special Issue Medication Management in Care Transitions)
Pharmacists in primary care settings have unique opportunities to address the causes of ineffective care transitions. The objective of this study is to describe the implementation of a multifaceted pharmacist transitions of care (TOC) intervention integrated into a primary care practice and evaluate the effectiveness of the program. This was a two-phase pilot study describing the development, testing, and evaluation of the TOC program. In Phase 1, the TOC intervention was implemented in a general patient population, while Phase 2 focused the intervention on high-risk patients. The two pilot phases were compared to each other (Phase 1 vs. Phase 2) and to a historical control group of patients who received usual care prior to the intervention (Phase 1 and Phase 2 vs. control). The study included 138 patients in the intervention group (Phase 1: 101 and Phase 2: 37) and 118 controls. At baseline, controls had a significantly lower LACE index, shorter length of stay, and a lower number of medications at discharge, indicating less medical complexity. A total of 344 recommendations were provided over both phases, approximately 80% of which were accepted. In adjusted models, there were no significant differences in 30-day all-cause readmissions between Phase 2 and controls (aOR 0.78; 95% CI 0.21–2.89; p = 0.71) or Phase 1 (aOR 0.99; 95% CI 0.30–3.37; p = 0.99). This study successfully implemented a pharmacist-led TOC intervention within a primary care setting using a two-phase pilot design. More robust studies are needed in order to identify TOC interventions that reduce healthcare utilization in a cost-effective manner. View Full-Text
Keywords: transitions of care; primary care; readmissions; pilot study transitions of care; primary care; readmissions; pilot study
MDPI and ACS Style

Slazak, E.; Shaver, A.; Clark, C.M.; Cardinal, C.; Panthapattu, M.; Prescott, W.A., Jr.; Will, S.; Jacobs, D.M. Implementation of a Pharmacist-Led Transitions of Care Program within a Primary Care Practice: A Two-Phase Pilot Study. Pharmacy 2020, 8, 4.

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