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Hahn et al
rates were significantly lower in the intervention group
versus the control group (6.9% vs 20%, P = 0.019).
In addition, programs that are designed to target patients,
prospectively and in real-time, who are at high risk of readmission using a multidisciplinary approach are sustainable
and affordable. A 2013 study by Amarasingham et al incorporated an e-Model that identifies hospitalized HF patients at
high risk of readmission and subsequent initiation of a multidisciplinary intervention. By using this targeted approach
they were able to decrease the HF readmission rate at a large,
urban tertiary care center from 26.2% to 21.2% (P = 0.01).
This e-Model was later trademarked as PIECES.9
Although pharmacist involvement in transitions of care
has shown benefit either alone or in multidisciplinary interventions, to our knowledge, there are no studies that have
evaluated the comparative effectiveness of different pharmacist visit types on reducing readmission rates. This study will
evaluate post-discharge care provided by either a clinical
pharmacy specialist (CPS) with CPA, MTM pharmacist
without CPA, or no pharmacist and their impact on all-cause
and HF readmission rates.

discharge appointment with the CPS near time of hospital
discharge. Patients received a telephone follow-up call to
notify of upcoming post-hospital discharge appointment
with the CPS. Interventions provided by the CPS with CPA
included similar interventions to MTM pharmacists such as
providing adherence tools and educating on therapeutic lifestyle changes, medication adherence, and disease states.
However, interventions also included ordering referrals
(primary care physician [PCP], nutrition, smoking cessation, medication access specialist, and anticoagulation management), making therapeutic medication changes including
medication discontinuations and initiations, ordering medication refills and labs, and triaging acute issues by admitting
patients directly to the Emergency Department (ED). The
CPA also allowed the pharmacist to provide follow-up care
during the 21-days post-hospital discharge with a second
visit within 7 to 21 days of the initial visit, depending on the
acuity of symptoms and patients' understanding of diet,
fluid intake, and medication adherence. Patients were discharged from the CPS clinic if clinically stable with appropriate follow-up.

Method

Arm 2 (Low Intensity Bundle). Patients were identified during
hospital admission when a consult was ordered for pharmacist medication discharge counseling. Patients were then
scheduled a post-hospital discharge appointment with the
MTM pharmacist with the goal to be seen within 10 days
after discharge. Patients were provided information describing MTM services in the hospital and were scheduled to have
a telephone or face-to-face visit after the initial hospital
encounter. Interventions provided by the MTM pharmacist
without CPA included reconciling medications, providing
adherence tools, educating on therapeutic lifestyle changes,
medication adherence, and disease states, providing information on when to seek ED care, coordinating care, and providing recommendations to physicians to optimize therapy.

Patients
A single-center, retrospective cohort study was conducted
from January 1, 2015, to July 31, 2017. Criteria for inclusion
were patients with a HF exacerbation index admission and
were at least 18 years old. Criteria for exclusion were patients
who were identified by the PIECES e-Model as being at high
risk for readmission who received an intensive bundle of
coordinated multidisciplinary services, had a diagnosis of
end-stage renal disease (ESRD), were actively incarcerated,
had admission to the inpatient psychiatric facility, were
actively pregnant, were enrolled in hospice care, had completed appointments with both a CPS with CPA and MTM
pharmacist without CPA post-discharge, or were seen in congestive heart failure (CHF) clinic. Patients were randomly
assigned to each bundle. This study was approved by
University of Texas at Southwestern Institutional Review
Board. Data were extracted from the electronic medical
record (EMR).

Description of Pharmacy Services Provided in
Each Study Arm
Arm 1 (High Intensity Bundle). Patients seen by a CPS were
managed under a CPA with cardiology physician supervision recognized by the Texas State Board of Pharmacy and
were scheduled with the goal to be seen within 10 days after
discharge. Management of HF and other chronic disease
states were based on the most current national clinical practice guidelines. Patients were randomly identified when
admitted in the hospital and were scheduled a post-hospital

Arm 3 (Standard Care). Patients in the control arm had a pharmacist consult for discharge counseling ordered during the
index admission. However, they did not receive a follow-up
appointment with either a MTM pharmacist or CPS after discharge due to limited resources.
All patients may have received additional appointments
with their PCP and/or other specialty clinics not mentioned
in the exclusion criteria.

Outcomes
The primary outcome assessed was the rate of 30-day allcause readmissions of HF patients seen by a CPS with CPA,
MTM pharmacist without CPA, and patients who did not
have a pharmacist visit after hospital discharge. Secondary
outcomes included rate of 30-day HF readmissions, number
of ED visits, average number of days until hospital readmission,
adherence to follow-up pharmacist appointments, average

Hospital Pharmacy - December 2019

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