Implementation of a Clinical Pharmacy Specialist-Managed Telephonic Hospital Discharge Follow-Up Program in a Patient-Centered Medical Home

Abstract

The objectives of this retrospective study were to examine the feasibility and characteristics that define successful implementation of a Clinical Pharmacy Specialist (CPS) telephonic hospital discharge follow-up quality improvement initiative, as well as the impact of this initiative. Adult patients who were discharged from a safety-net hospital between July 1, 2010 and June 30, 2011 and who were part of a patient-centered medical home were included in this quality improvement initiative. CPSs attempted to contact 470 patients; of those, 207 received the intervention and 263 did not. Patients in the contacted group were more likely to attend a hospital discharge follow-up appointment (66.2% vs. 44.5%, P<0.01) and had lower rates of 30-day readmission (22 vs. 52, P<0.01) compared to those who were not contacted. Institutions should consider allocating resources for pharmacist-managed posthospital discharge follow-up services because of the potential for positive clinical and financial impact. (Population Health Management 2013;16:235–241)

Introduction

H ospital discharge can be a time of confusion for patients, especially with regard to medication use. Patients often return home with alterations to their prehospitalization medication regimen, including dose adjustments or discontinuation of prehospitalization medications and the addition of new medications. As many as 1 in 5 patients experiences a posthospital discharge adverse event, and of these events, approximately two thirds are medication related.¹ Medication-related issues that patients may experience post discharge include difficulty obtaining medication refills and/or difficulty paying for medications, taking an additional medication(s) not on their discharge medication list, not taking a medication(s) on their discharge list, taking a different dose or frequency, and taking a medication in the same class as one already prescribed.²

Implementation and examination of posthospital discharge services such as pharmacist-based telephone management is a timely topic. Data from the Centers for Medicare and Medicaid Services (CMS) show that as many as 18% of Medicare beneficiaries are readmitted within 30 days of their initial hospital discharge and 13% of these readmissions are likely avoidable. These unnecessary readmissions translate into potentially $12 billion in avoidable spending.³ Because of the magnitude of these costly readmissions and their negative effects on patients' quality of life, CMS is considering payment adjustments for avoidable readmissions that occur as a result of not following evidence-based practices, as well as performance-based incentives to reward institutions that are using best practices to improve their performance.⁴ Previous studies have suggested that low-income and minority patients are at greatest risk for hospital readmission,^5,6 and that site of care also was independently associated with readmission,⁵ although the causes of these disparities are not understood. This suggests that institutions that serve minorities may suffer disproportionately from proposed penalties by CMS unless successful programs to reduce hospital readmission are instituted in these organizations.⁵

Pharmacist-based telephone follow-up is one of many potential approaches to prevent medication-related problems in patients during the posthospital discharge time period. Several studies have evaluated the effectiveness of such pharmacist-based telephone intervention programs, either as part of a multidisciplinary approach or as a pharmacist-only intervention.^2,7

–10 In these studies, hospital- or unit-based pharmacists contacted English-speaking patients who were being discharged from general medicine services. These studies showed pharmacists to be effective at preventing and reducing medication-related adverse drug events (ADEs) post hospitalization through patient counseling and resolution of missing prescriptions or prescription errors.^2,7

–10 Intervention by a pharmacist, either alone or as part of a team, also has been shown to reduce emergency department visits and hospital readmissions.^7,8,10

Although positive in nature, the studies conducted previously neither identified nor intervened with patients within a patient-centered medical home (PCMH) model. In other words, the patients included in the aforementioned studies were identified based on their admittance to a particular hospital service and were contacted by pharmacists affiliated with the hospital or a specific ward within the hospital. The authors of the current study implemented a quality improvement (QI) initiative that consisted of a telephonic hospital discharge intervention that targeted established patients at a single outpatient clinic site and utilized clinical pharmacy specialists (CPSs) who had a working relationship with patients' primary care providers (PCPs). This intervention focused on the coordinated care aspect of PCMH aimed at improving coordination during transitions of care, such as when patients are being discharged home from the hospital. The purpose of this study was several fold: to examine the feasibility and characteristics that define successful implementation of a CPS telephonic hospital discharge follow-up QI initiative, as well as the impact of this initiative. To this end, the authors will describe the characteristics of the patients included in this intervention, logistics of carrying out the intervention, and determine the rates of attendance at follow-up appointments within 30 days post hospital discharge, as well as 30-day readmission for patients who were able to be contacted with the telephonic intervention compared with those who were not.

Methods

Study design and patients

This retrospective study included patients in the hospital discharge follow-up QI initiative at the Denver Health Eastside Adult Internal Medicine Clinic who were discharged from Denver Health Medical Center (DHMC) between July 1, 2010 and June 30, 2011. This study was approved by both the Denver Health Sponsored Programs and Research Office and the Colorado Multiple Institutional Review Board. DHMC is the safety-net institution for the city and county of Denver, Colorado; the patient population served is ethnically diverse and socioeconomically underprivileged.

Inclusion criteria

Adult patients (age ≥18 to 89 years of age) who were identified as having an Eastside Adult PCP in their PCP field and were discharged from the hospital medical and surgical services between July 1, 2010 and June 30, 2011 were included in this retrospective review.

CPS intervention

The telephonic discharge follow-up was performed by residency-trained CPSs and their trainees (under CPS supervision) at the outpatient adult internal medicine clinic. The CPSs had access to the patients' electronic health records (EHR) and had a working relationship with the patients' PCPs. Telephone follow-up was performed within 48 to 96 h of hospital discharge. Each completed or attempted telephone call was documented on a barcoded telephone encounter form that was scanned into the patient's EHR.

Data collected included patient demographic characteristics (age, body mass index, sex, self-reported race/ethnicity, insurance status, marital status, and baseline comorbidities); index hospitalization information (hospital service, length of stay, discharge diagnosis, whether a follow-up appointment was scheduled at the time of discharge); whether patients were successfully contacted 48 to 96 h post hospital discharge; whether patients attended 30-day follow-up appointments; and whether these patients were readmitted to DHMC within 30 days post discharge for any reason. Presence of a readmission within 30 days was determined by identification of a hospital registration in the EHR for individual patients. Attendance at follow-up appointments within 30 days of discharge was confirmed by visit attendance in the appointment system and by chart review.

Study groups

Patients were categorized into 2 groups based on whether the CPS was able to contact the patient within 48 to 96 h post hospital discharge. The contacted group included patients who were successfully contacted and who received the intervention, and the not contacted group included patients who either received a voice message (either electronically or as a message left with a person other than the patient) or were unable to be contacted telephonically by the pharmacist.

Statistical analysis

Baseline characteristics of the contacted and not contacted groups were compared using t tests or Wilcoxon rank sum tests for continuous variables, and chi-square or Fisher exact tests for dichotomous or categorical predictors. The a priori level of significance for these comparisons was defined as P<0.05. Baseline comorbidities were defined using combinations of billing codes and laboratory values. These comorbidities were counted as present at baseline if they were diagnosed and coded at visits within the previous 12 months of the index hospitalization date. Stepwise multivariable logistic regression analysis was utilized to identify predictors of the primary outcome (30-day readmissions). Covariates were considered candidates for inclusion in the model if the P value on bivariate testing was <0.25. To derive the final model, variables were excluded using backward elimination until all P values were<0.05.

Results

Patient characteristics

The population studied included 470 patients who were discharged from DHMC between July 1, 2010 and June 30, 2011. The contacted group included 207 patients who were contacted and received the intervention and the not contacted group included 131 patients who were left voice messages and 132 who were unable to be contacted (n=263). Of the patients who received a message (n=131), two thirds were left a voice mail and the remaining one third had a message left with a family member, caseworker, or friend. In the subgroup that was unable to be contacted (n=132), almost one-quarter had a disconnected telephone number and nearly 40% had a working telephone number that was not answered. Comparison of the demographic characteristics and baseline comorbidities of the contacted and not contacted groups is presented in Table 1. Patients in the contacted group were more likely to be older and have Medicare insurance, whereas patients in the not contacted group were more likely to have Medicaid insurance and chronic obstructive pulmonary disease (COPD). All other baseline characteristics were similar between groups.

Table 1.

Demographics of the Study Population

	Contacted (n=207)	Not Contacted (n=263)	P value
Age (years)
Median (IQR)	57 (50, 67)	55 (48, 62)
Range	19–87	23–89	0.02^a
Male sex N (%)	88 (42.5)	135 (51.3)	0.06
BMI (kg/m²)
Median (IQR)	28.1 (23.9, 35.4)	26.9 (22.8, 32.5)
Range	14.4–58.5	15.3–57.4	0.08^a
Race/ethnicity N (%)
African American	103 (50.2)	131 (50.6)
Hispanic/Latino	49 (23.9)	67 (25.9)
White	53 (25.9)	61 (23.6)	0.81
Insurance type N (%)
Medicare	99 (48.5)	85 (33.0)
Medicaid	56 (27.5)	113 (44.0)
Uninsured	49 (24.0)	59 (23.0)	<0.01
Marital status N (%)
Single/divorced/widowed	193 (93.2)	248 (94.3)
Married/other	14 (6.8)	15 (5.7)	0.64
Comorbidities at baseline N (%)
DM	88 (42.5)	108 (41.1)	0.72
CHF	63 (30.4)	80 (30.4)	0.99
COPD	69 (33.3)	112 (42.6)	0.04
Asthma	59 (28.5)	97 (36.9)	0.06
Cancer	45 (21.7)	53 (20.2)	0.67

BMI, body mass index; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; IQR, interquartile range.

Wilcoxon Rank Sum Test.

Telephone call characteristics

The length of time spent reviewing the patients' EHR data and completing the follow-up telephone calls varied greatly, depending on the number of patients contacted and the extent of the conversation with each patient, but on average took between 15 and 120 min each day, Monday through Friday. If a patient was not able to be reached or if a voice mail message was left, the telephone call duration was approximately 1 min; however, if a patient was successfully contacted, the telephone call lasted between 5 to 30 min. Examples of the types of information discussed during the follow-up telephone calls included confirmation that patients received the appropriate medications at discharge, discussion of new medications or new medication doses, confirmation of scheduled follow-up appointments, and clarification of patients' questions regarding discharge information.

Characteristics of the index hospitalization

Detailed data on the characteristics of the index hospitalization are presented in Table 2. The most common diagnosis upon discharge was infection (excluding pneumonia) or sepsis in the contacted group and COPD or asthma in the not contacted group, but both groups had similar rates of selected discharge diagnoses (data not shown). At the time of hospital discharge, a higher percentage of patients in the contacted group had scheduled follow-up appointments compared to the not contacted group (P=0.02). None of the characteristics of the index hospitalization were statistically different between groups with the exception of scheduled follow-up appointments at the time of discharge.

Table 2.

Characteristics of the Index Hospitalization

	Contacted (n=207)	Not Contacted (n=263)	P value
Hospital service N (%)
General medicine	174 (84.1)	234 (89)
Surgery	24 (11.6)	18 (6.8)
Other	9 (4.3)	11 (4.2)	0.20
Length of stay (days)
Median (IQR)	2 (1, 4)	2 (1, 4)	0.54^a
≤6 days n (%)	187 (90.3)	233 (88.6)	0.54
Scheduled follow-up appointments at discharge n (%)	144 (69.7)	155 (58.9)	0.02

IQR, interquartile range.

Wilcoxon Rank Sum Test.

Interventions performed

The CPSs discussed follow-up appointments and/or provided appointment reminders for 193 of 207 patients (93.2%) in the contacted group. Twenty-two patients (10.6%) required a specific intervention, which were grouped into 5 main categories: (1) medication counseling, (2) nonmedication counseling, (3) anticoagulation counseling/follow-up, (4) medication refill/pick-up assistance, and (5) other. The authors selected 1 example from each category to describe in more detail; these interventions are presented in Table 3.

Table 3.

Selected Specific Interventions Performed by Clinical Pharmacy Specialists

Category	Example intervention
Medication counseling	Patient was diagnosed with left foot cellulitis due to MRSA and sent home with a prescription for doxycycline. The patient reported being nauseated by the antibiotic, and so was taking it with food. The CPS educated the patient on appropriate administration of doxycycline, including spacing it from dairy or calcium-containing products.
Nonmedication counseling	Patient was admitted for hypertensive urgency secondary to medication nonadherence. The patient was discharged on a low-sodium diet but did not know what this meant. The CPS discussed a low-sodium diet and reviewed the sodium content of common food items with the patient.
Anticoagulation counseling	Patient is chronically anticoagulated for recurrent PE and was admitted for ADHF. The patient's warfarin was held for a cardiac catheterization procedure and it was reinitiated post procedure with dalteparin as a bridging agent. The CPS discussed appropriate SC injection technique as well as dietary and fluid restrictions with the patient.
Medication refill/pick-up assistance	Patient was admitted for a flare of his stage IV pulmonary sarcoidosis and was placed on a prednisone taper. The patient also has diabetes and requested refills on both his fluticasone inhaler and insulin NPH, so the CPS contacted the patient's PCP and facilitated getting those refills. The CPS also followed up with the patient a week later to adjust insulin dose when patient completed his prednisone taper.
Other	Patient was admitted for angioedema secondary to lisinopril. The patient was instructed to monitor BP at home, but did not have a home BP monitor. The CPS worked with the patient's PCP to fill out and fax the DME request to obtain the home BP monitor.

ADHF, acute decompensated heart failure; BP, blood pressure; CPS, clinical pharmacy specialist; DME, durable medical equipment; MRSA, methicillin-resistant Staphylococcus aureus; NPH, neutral protamine hagedorn; PCP, primary care provider; PE, pulmonary embolism; SC, subcutaneous.

Primary outcomes

Patients who were successfully contacted by a CPS had higher rates of attendance at scheduled follow-up appointments within 30 days of hospital discharge and lower rates of 30-day readmission compared with those who were not (137 [66.2%] vs. 117 [44.5%] patients who attended appointments and 22 [10.6%] vs. 52 [19.8%] readmissions, P<0.01 for each).

Predictors of 30-day readmission

In the unadjusted model, presence of Medicaid insurance, diabetes, COPD, and asthma were associated with a higher likelihood of 30-day readmission (Table 4). However, in the adjusted model, only presence of diabetes was associated with a higher likelihood of 30-day readmission. Importantly, in both the unadjusted and adjusted models, the CPS intervention was associated with a reduced likelihood of 30-day readmission.

Table 4.

Unadjusted and Adjusted OR and 95% CI for Variables Associated with Readmission

	Unadjusted OR	P value	Adjusted OR	P value
Contacted by clinical pharmacist	0.48 (0.28–0.83)	<0.01	0.46 (0.27–0.80)	<0.01
Age (years)
19–49	1.40 (0.80–2.44)
50–64	Reference
65+	0.68 (0.34–1.36)	0.15
Male sex	1.37 (0.83–2.25)	0.22
BMI (kg/m²)
<23	1.94 (0.92–4.07)
≥23 –<27	1.64 (0.76–3.54)
≥27 –<33	Reference
≥33	1.54 (0.73–3.26)	0.37
Race/ethnicity
African American	Reference		Reference
Hispanic/Latino	0.69 (0.35–1.37)		0.63 (0.32–1.26)
White	1.47 (0.83–2.60)	0.12	1.67 (0.93–3.03)	0.04
Insurance type
Medicare	Reference
Medicaid	1.93 (1.10–3.39)
Uninsured	0.83 (0.40–1.74)	0.02
Marital Status
Single/divorced/widowed	Reference
Married/other	0.18 (0.02–1.34)	0.09
Comorbidities at baseline
DM	2.06 (1.25–3.41)	<0.01	2.41 (1.43–4.07)	<0.01
CHF	1.49 (0.89–2.50)	0.13
COPD	1.75 (1.06–2.88)	0.03
Asthma	1.79 (1.08–2.96)	0.02
Cancer	1.51 (0.85–2.67)	0.16

BMI, body mass index; CHF, congestive heart failure; CI, confidence interval; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; OR, odds ratio.

Discussion

These findings add to the body of literature regarding the role of CPS involvement in the transition of patients from the inpatient to the outpatient setting. Pharmacists are well positioned to assist patients during this transition because of their extensive medication knowledge. This study evaluated the feasibility and effectiveness of a telephone-based CPS intervention in an outpatient PCMH that serves a low-income, minority, publicly-insured or uninsured patient population.

Previously, Schnipper and colleagues² found that pharmacist telephone follow-up 3 to 5 days post discharge resulted in fewer preventable ADEs in that group at 30 days post discharge (1% phone call vs. 11% no phone call, P=0.01).² The current study did not specifically track and evaluate ADEs but, based on the interventions made by the CPS regarding patients' medications, it is probable that ADEs could be prevented or ameliorated (Table 3). A study by Jack and associates⁸ showed a lower rate of hospital utilization in the intervention group (multidisciplinary hospital discharge planning and education plus pharmacist telephone follow-up 2 to 4 days post discharge) at 30 days post discharge.⁸ Hospital utilization was 0.314 versus 0.451 visits per person per month in the intervention and control groups, respectively (P=0.009).⁸ The current study focused solely on CPS telephone follow-up and observed a 9% absolute lower 30-day readmission rate in patients who were successfully contacted versus those who were not. The reduction in readmissions translates to potential cost savings to the institution. The estimated cost of an admission to the authors' institution is between $10,000 and $15,000 based on Medicare data; if these admission costs are extrapolated to estimate the savings of the 30 fewer readmissions that occurred in the contacted group, the cost savings potential is between $300,000 and $450,000. Because DHMC cares for a disproportionate number of uninsured patients (approximately 25% of the patient population in this study; 40% of the DHMC total population), readmissions often have a negative financial impact as there is no insurance reimbursement to offset the cost. Additionally, provisions in the Patient Protection and Affordable Care Act likely will lead to hospital payment adjustments for readmissions related to heart failure, acute myocardial infarction, and pneumonia. As part of the payment adjustment, institutions will be penalized financially for “excess readmissions” related to these conditions.

On average, the CPSs in the current study spent 10 hours per week (20% of their salaried time) or less performing the intervention. Across the country there is a wide range of salaries for CPSs; however, using an estimated average annual outpatient CPS salary of $100,000, this intervention cost less than $20,000 to perform. Based on the cost savings estimates discussed, the potential cost savings for avoiding or preventing readmissions far outweighs the expense of performing the intervention. The positive financial impact realized by preventing readmissions could justify the hiring of a CPS in this capacity based on absolute reduction in readmissions and average cost of a readmission to DHMC or at a similar safety-net hospital.

It also is necessary to discuss studies that focused solely on telephone follow-up by pharmacists to compare and contrast the logistics and impact of the results of the current study. Burniske et al found that patients who received a postdischarge phone call were 18% less likely to be readmitted within 30 days of their incident hospitalization.⁷ A study by Dudas et al¹⁰ determined there to be significantly fewer emergency department visits within 30 days of discharge among patients who received a postdischarge telephone call 2 days after their discharge (10% phone call vs. 24% no phone call, P=0.005) and a trend toward fewer 30-day readmissions in the same group (15% phone call vs. 25% no phone call, P=0.07).¹⁰ In the current study, patients who received a postdischarge phone call from a CPS were 50% less likely to be readmitted compared to those who did not. This study utilized CPSs who practice in an outpatient adult internal medicine clinic in which patients have an established PCP, which is different from the Burniske and Dudas studies that involved pharmacists from the inpatient setting performing telephone follow-up. This is an important difference to note because the CPSs in the current study were an integral part of the clinic's PCMH and had a direct working relationship with all of the PCPs; in many instances they also were familiar with the patients from other CPS-run clinics (anticoagulation, hypertension, and diabetes clinics). In several instances, the CPS worked directly with the patient's PCP to order medication refills or obtain authorization for durable medical equipment (Table 3). Because of the streamlined communication of this working relationship, the CPS improved patient access to the health care system post discharge. In addition, the ability to communicate directly with patients on behalf of their PCP increased the credibility of the CPS and allowed for more timely identification and resolution of any conflicting discharge information. A lack of a direct working relationship could produce challenges in the opposite direction of what has been described, including less trust of the CPS by patients, lengthier time to problem resolution, and absence of a defined medical home for the patient. The addition of these study findings to the previous studies helps to substantiate the positive impact that CPS telephone discharge follow-up can have on hospital utilization in a safety-net health system.

Another important feasibility and patient familiarity aspect already alluded to is the concept that the CPSs already worked in the patients' medical home and were familiar with the patients being contacted. The CPSs at this clinic performed in person and telephonic management of anticoagulation, diabetes, and hypertension. Because in many instances the CPSs had already established rapport from a previous encounter, the patients who were contacted for hospital discharge follow-up knew and trusted the intervention the CPSs were performing.

In addition to telephone follow-up, timely PCP follow-up also has been shown to reduce unnecessary hospital readmissions. Misky and colleagues¹¹ found that patients who did not follow up with their PCP within 4 weeks had a 10 times higher rate of readmission compared to patients who had PCP follow-up within 4 weeks of discharge.¹¹ It has been proposed that timely PCP follow-up could aid in preventing medication-related ADEs and errors in the early postdischarge time period. The current study showed that 68% of patients who were contacted, versus 46% of those not contacted, attended follow-up appointments within 4 weeks, whether scheduled at the time of discharge or afterward. This result reinforces the impact of telephone follow-up with patients after discharge as a means to improve timely PCP follow-up with the ultimate goal of preventing ADEs and readmissions.

This study adds further support for the involvement of ambulatory care CPSs in improving patients' transitions from the inpatient to the outpatient setting, particularly within a PCMH model. Appropriately trained and qualified ambulatory care CPSs are knowledgeable about a variety of disease states and related medication therapies, which in turn allows them to be effective in assisting with discharge issues related to general medicine admissions. The American College of Clinical Pharmacy has published position statements attesting to the benefits of pharmacists completing residency training and obtaining board certification with an ultimate goal of enhanced provision of patient care.^12,13 Additionally, CPSs in the ambulatory care setting are uniquely positioned to improve these transitions by being physically present in the clinic setting and thus able to optimize patient medication counseling and timely follow-up with PCPs. This role is strengthened when CPSs have access to the patient's hospitalization EHR. Previous studies not involving pharmacists in the hospital discharge intervention have not resulted in substantial impact. One study examining the effect of a postdischarge follow-up arrangement and another study examining an intensive nurse and physician intervention post discharge showed no difference in hospital readmissions and increased rates of readmission, respectively.^14,15

This study has several limitations. First, the retrospective nature and lack of randomized study design limits the ability to evaluate the causality of the CPS interactions related to PCP follow-up and 30-day readmissions. The population who were unable to be contacted could be inherently different from the contacted group and thus could have confounded the results. The only statistical difference noted between the groups was a higher rate of Medicaid patients in the not-contacted group, which is expected based on previous evaluations.^16
–18 Based on chart review at the time of the telephonic intervention, rehospitalization was not a factor related to the inability to intervene with the not-contacted group. Despite performing a multivariate regression analysis, there still may be residual confounding present related to unmeasured confounders. Second, the authors were able to measure readmissions to only 1 institution, which could have underestimated the rate of hospital readmission. The authors are unable to fully estimate the rate of readmission to other institutions; however, there is a financial incentive for uninsured patients to be hospitalized at DHMC because they are charged co-pays on a sliding scale program versus being charged the entire cost of hospitalization. Based on data from the DHMC Medicare and Medicaid managed care population (n=178 [37.9%]), only 15% of patients who get readmitted are admitted to outside facilities. Potential explanatory factors for readmissions in this analysis, such as ADEs, were not able to be tracked but this limitation is common in previously published studies with a similar population focus.

Conclusion

CPSs in the ambulatory care setting are well positioned to improve patient transitions of care from the inpatient to outpatient setting based on their extensive medication knowledge and ties to patients' clinic care within a PCMH model in a safety-net health system.

An intervention focused on telephonic follow-up by CPSs can be associated with an increase in patient attendance at postdischarge follow-up appointments and a lower 30-day readmission rate compared with patients who are not able to be contacted. Because of the positive clinical and financial impact of this type of intervention, institutions should consider allocating resources for posthospital discharge follow-up services that include CPSs.

Footnotes

Acknowledgment

The authors thank Brenda Beaty, MSPH in the Colorado Health Outcomes Program for her assistance with data analysis.

Author Disclosure Statement

Drs. Anderson, Marrs, Vande Griend, and Hanratty declared no conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors received no financial support for the research, authorship, and/or publication of this article.

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