RESUMEN
OBJECTIVE: Nearly one in five Medicare patients is readmitted to a hospital within 30 days of discharge. Most of these admissions are preventable, coming at a cost both to the patient's health and function and resulting in unnecessary health expenditures. With nearly two-thirds of postdischarge adverse events attributed to medications, pharmacists are uniquely suited to implement a homebased care transitions program with the goal of reducing unnecessary 30-day readmissions. SETTING: Our model of care, which has been implemented by Medicare Advantage plans in Massachusetts and California, focuses on the transition from the acute and subacute setting to home. PRACTICE DESCRIPTION: Within the first few days following discharge from acute or subacute facilities, the pharmacist visits patients in their homes. PRACTICE INNOVATION: In collaboration with other health care providers, the pharmacist reconciles and optimizes medications from the multiple settings of care. In addition, he or she provides care management and ongoing support for 30 days postdischarge. MAIN OUTCOME MEASUREMENTS: The pharmacists' involvement in an interdisciplinary home-based transitions of care program provides patients with medication and care-management interventions that reduce 30-day readmission rates. RESULTS: Over the past two years, Dovetail Health has demonstrated up to 30% reductions in network readmission rates for our health plan and provider group partners. CONCLUSIONS: The novel role of the pharmacist in managing patient transitions of care from one site to another not only reduces unnecessary health care utilization and cost, but more importantly benefits the patient, who remains healthy at home following a hospitalization.
