Community-based care transitions program: Pharmacist interventions (CCTP)

Background: Congestive heart failure is the most common Medicare discharge diagnosis, and is more costly than any other diagnosis. In 2009, CMS added congestive heart failure readmission as a required and publicly reportable measure under the Reporting Hospital Quality Data for Annual Payment Update. In 2010 the Patient Protection and Affordable Care Act implemented penalties to hospitals whose readmissions were above federally set limits. This legislation is set to add COPD as another quality measure in 2014. COPD is the third leading cause of death within the US and accounts for over 600,000 hospitalizations annually. Often patients readmit due to non-adherence, or incorrect medication administration. While Care Management and Transitions programs exist within institutions reduce the risk of readmissions, it is the ambulatory care pharmacist's unique position that allows for expertise medication education and adherence counseling.

Purpose: To determine if pharmacist provided MTM and DSM to CHF and /or COPD patients with a recent hospitalization or emergency department visit due to exacerbation will reduce same-cause readmission at 7, 30, and 60 days. Secondary outcomes include identification of polypharmacy, medication discrepancies between institutions, and frequency of rehospitalization.

Methods: Pharmacists belonging to the patient centered medical home, Penobscot Community Healthcare in Bangor Maine, as part of the accountable care organization, review local in-hospital patient censuses. The pharmacist then identifies patients with either CHF and/or COPD exacerbation via shared health records between institutions. The pharmacist then conducts Medication Therapy Management (MTM) and Disease State Management (DSM) either in the primary care facility, or within the patient's home. Medication Therapy Management is in accordance with the certification: Delivering Medication Therapy Management in the Community, as sponsored by the American Pharmacist Association. Information among in-patient and out-patient health systems is shared via Maine's HealthInfoNet. Data is collected via retrospective chart review, and accessed via electronic health records (Centricity CPS 10 Client). Outcomes: Results are pending, as a stop-date for data collection is set at May 20th, 2012.