Impact of Student Pharmacist-Led Transition-of-Care Services on 30-Day Hospital Readmissions at a University Call Center.

Background: Transition of care (TOC) refers to the movement of patients between different health care settings due to changes in medical conditions and needs. Pharmacists can play an important role in TOC services as polypharmacy is a common reason for hospital readmission that costs the US taxpayers an average of $17 billion annually. Objective: The purpose of this study is to evaluate the impact of TOC telehealth services provided by pharmacy students at a university-based call center on 30-day hospital readmission. Methods: In this retrospective observational study, an electronic chart review was conducted for patients who were discharged from the hospital and received a telephone call from pharmacy students. Patients were referred to the pharmacy team from a primary care provider office. The co-primary endpoints were the number of 30-day all-cause hospital readmissions (including emergency department visits) and 30-day readmission due to initial admission diagnosis in patients who received a telephonic TOC call from a pharmacy student compared with patients who declined or were unable to be reached. Types of pharmacy-related TOC interventions provided by students were also collected. Results: A total of 84 patients were included in this study. All-cause 30-day readmission was similar between groups (13% vs 15.8%), whereas 30-day readmission due to initial admission diagnosis was much lower in the intervention group (5.9% vs 11.1%). Although a positive trend was observed in favor of the intervention group, a statistically significant difference was not observed for both 30-day all-cause readmission and 30-day readmission due to initial admission diagnosis. Medication reconciliation, adherence counseling, and lifestyle education (diet, exercise) are the most common topics discussed with the patients during TOC interventions. Conclusion: Using student pharmacists to provide postdischarge TOC calls can be a benefit to the patient and the health care team while offering pharmacy students valuable learning experience prior to graduation.

Evaluating Pharmacist-Driven Interventions in a Primary Care Setting to Improve Proportion of Days Covered and Medication Adherence.

BACKGROUND: Medication nonadherence is the leading cause of poor health outcomes and increased risk of hospitalizations. Previous studies have shown that pharmacist interventions can help improve medication adherence and CMS quality measures. OBJECTIVE: The purpose of this study was to examine the impact of clinical pharmacists' interventions on medication adherence and PDC scores for ACEi/ARBs, statins, and noninsulin antidiabetic medications in the primary care setting. METHODS: This observational study was conducted at four primary care clinics to evaluate PDC scores pre- and post-pharmacist interventions from April 2020 to December 2020. Eligible patients were Humana Part D beneficiaries with a baseline PDC score <85%. The primary outcome of this study was to evaluate the average change in final PDC scores, and 1-month change in PDC scores following a pharmacist intervention. Secondary outcomes were number and types of adherence barriers identified, interventions provided by the pharmacist, and barriers and interventions category (pharmacy, patient or physician-related). RESULTS: A total of 89 barriers were identified and 208 interventions were completed. A statistically significant difference in the average change of final PDC score from baseline was seen among those on ACEi/ARBs (72.5 to 78.0, p = 0.004) and statins (73.3 to 76.6, p < 0.001). Similarly, a statistically significant change was observed from baseline to 1-month PDC among those on ACEi/ARBS (72.5 to 75.4, p = 0.001) and statins (73.3 to 74.9, p < 0.001). Conclusion: Pharmacists located in a primary care setting improved medication adherence and PDC score for patients on ACEIs/ARBs and statins.

Are SERMs safe and effective for the treatment of hypogonadism in men?

YES. For both normal-weight and obese men with low testosterone levels and hypogonadal symptoms, selective estrogen receptor modulators (SERMs), such as clomiphene citrate (CC) and enclomiphene citrate (EC), appear to be effective and safe for improving serum testosterone levels (strength of recommendation [SOR]: C, disease-oriented outcomes from randomized controlled trials [RCTs] and cohort studies). Studies also show that symptom improvement is comparable to that with exogenous testosterone replacement and similar to eugonadal men (SOR: B, patient-oriented outcomes from retrospective cohort studies).

Development of a combination didactic-experiential elective course within a college-based pharmacy call center.

BACKGROUND: Pharmacy graduates should be prepared to provide patient care in a variety of healthcare settings as members of an interprofessional collaborative team. College-based pharmacy call centers can serve as settings to promote interprofessional practice through didactic and experiential coursework. An elective course, Team-Based Medication Management Practices, was developed to provide student pharmacists the opportunity to learn about pharmacy-led services within value-based care models and to prepare them for interprofessional care by incorporating experiential activities within a college-based call center. EDUCATIONAL ACTIVITY: A two-credit elective course was offered to third-year pharmacy students. The course was delivered through a combination of didactic lectures and experiential activities within a college-based pharmacy call center, with modules focused on medication adherence, medication therapy management, and transitions of care. A survey was administered to students at the end of the course to evaluate perceptions. FINDINGS: Six students enrolled in the elective and completed the survey. Most students "strongly agreed" or "agreed" that they gained a better understanding of interprofessional care within value-based care models and pharmacy services that can be provided within a college-based call center while acquiring patient care skills. The role of telehealth in the delivery of pharmacist-led patient care services is likely to continue expanding as a result of the COVID-19 pandemic and it will become increasingly important to train students to provide these services.

Evaluating a Pharmacist-Led Intervention on Cardiovascular- and Diabetes-Related Quality Measures in a Primary Care-Based Accountable Care Organization.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) publishes quality measures to gauge performance in Accountable Care Organizations (ACOs). ACO-27 (Diabetes Mellitus: Hemoglobin A1c Poor Control) and ACO-41 (Diabetes: Eye Exam), are 2 components for the Diabetes Composite measure. ACO-42 focuses on Statin Therapy for the Prevention and Treatment of Cardiovascular (CV) Disease. There are limited studies regarding the pharmacist role in CV and Diabetes Management in the ACO primary care setting. OBJECTIVE: To evaluate the impact of pharmacist-led interventions on CV- and diabetes-related CMS quality measures within a primary care-based ACO. METHODS: This retrospective pre-post intervention study included 3 primary care-based ACO offices. Patients who met eligibility criteria for CMS quality measures ACO-27, -41 and -42 were included. Pharmacist interventions occurred in December 2018. The study co-primary outcomes were the percentage of patient meeting ACO-27/-41 (composite diabetes-related) and -42 (statin-related) CMS quality measures in the pre-intervention compared to the post-intervention phases. RESULTS: Of 105 patients meeting study inclusion criteria, 77.1% were on statin therapy prior to intervention. After pharmacist intervention, the prevalence of patients on statin therapy increased to 80.0% (p = 0.083). All patients had a HbA1c less than 9% pre-intervention. Sixty-one (58.1%) patients had a documented dilated eye exam prior to intervention. Post-intervention, the prevalence of exams increased to 73.3% (p < 0.0005). CONCLUSIONS: Pharmacists can assist primary care providers in the ACO setting meet CV- and diabetes-related CMS quality measures, demonstrating the value of the pharmacist in value-based health care settings.

Effects of a Therapeutic Interchange Between Branded and Generic Inhaled Therapy on Chronic Obstructive Pulmonary Disease.

Objective To evaluate the difference in the occurrence of chronic obstructive pulmonary disease (COPD) exacerbations six months preconversion compared with six months postconversion from the branded inhaled corticosteroid/long-acting beta 2-agonist inhalers to the generic fluticasone/salmeterol inhalers. Design Retrospective cohort study using a six-month pre-/post-test design Setting Three primary care offices within a Management Service Organization (MSO) in South Florida. Patients, Participants Patients were included in the study if they had a diagnosis of COPD (in electronic medical record [EMR]), were at least 18 years of age, were under the care of a provider at one of the three primary care clinics within an MSO, and were switched from a branded ICS/LABA inhaler to a generic ICS/LABA inhaler between May 2019 and February 2020. This study included a total of 22 patients. Interventions Not applicable; this was a retrospective chart review. Main Outcome Measure The prevalence of COPD exacerbations leading to hospitalizations, emergency room visits, urgent care visits, or clinic visits. Results In this study, 10 (45.5%) patients experienced at least one exacerbation while on generic inhaler therapy compared with four (18.2%) patients while on branded inhaler therapy (P = 0.05). Those on a generic inhaler were 3.8 times more likely to have a COPD exacerbation. Conclusion While changing patients from branded to generic inhalers may be appealing because of the potential benefits in cost-reduction, the results of this study conclude that the inhaler switch may lead to increased exacerbations. Prescribers need to be aware of potential complications that may be related to a therapeutic interchange.

impact of a Pharmacy-Led Transitions of Care Program Within a Primary Care-Based Accountable Care Organization.

OBJECTIVE: To assess the impact of pharmacist-led transitions of care program on 30-day readmission rates in the accountable care organization (ACO) primary care setting. DESIGN: Retrospective cohort study. SETTING: Two primary care provider (PCP) offices with an ACO in South Florida. PATIENTS, PARTICIPANTS: Adult Medicare patients who completed a post-discharge follow-up visit at two primary care offices within an ACO from July to December 2017. INTERVENTIONS: To supplement postdischarge visits with a PCP, the pharmacy services were also provided two days per week with a PCP. The comparator groups were patients who only saw a PCP or those who saw a PCP and pharmacist. MAIN OUTCOME MEASUREMENTS: The primary outcome was hospital readmission or emergency department visit within 30 days. RESULTS: A total of 190 subjects were included. There were 113 patients in the PCP group and 77 patients in the PCP/pharmacist group. There was a reduction in the primary outcome when comparing the PCP-only versus PCP/pharmacist groups (6.2% versus 3.9%; P = 0.74). CONCLUSION: Involving pharmacists in patient transitions of care in the primary care setting may be beneficial as previous studies have demonstrated. Further studies evaluating pharmacy services in emerging health care models are needed in order to most effectively utilize the expertise of the pharmacy team.

Training pharmacy residents as transitions of care specialists: a United States perspective.

Transitions of care has emerged as a point of vulnerability in global health care systems, which can lead to potential avoidable medical errors. In the United States, pharmacist-led transitions of care programs are increasing in number, with many hospitals offering discharge prescription services. However, the required training for these positions remains unclear. With the lack of accreditation standards by the American Society of Health-System Pharmacists for transitions of care as a post-graduate year 2 specialty, this leads to the unanswered question: Which pharmacists are qualified for the growing number of transitions of care positions? Whether trained in a formal transitions of care specialty residency or not, pharmacists as a profession should reassess the proper qualifications needed to provide transitions of care services. One central message remains clear in that having a pharmacist on any interdisciplinary team who is knowledgeable about inpatient and community settings and administrative tasks involved in transitions of care while understanding optimal evidence-based recommendations would appear to be an important piece to the puzzle.

Improving Medication Adherence in an ACO Primary Care Office With a Pharmacist-Led Clinic: A Report From the ACORN SEED.

BACKGROUND: As health care moves into the era of value-based medicine, both ambulatory and acute settings are being held accountable for the quality of care provided to patients. Previous studies have shown improved clinical outcomes through medication therapy management (MTM) due to improved medication adherence. OBJECTIVE: The purpose of this study is to assess the effects of a pharmacist-led MTM clinic in an accountable care organization (ACO) affiliated primary care office on adherence to renin-angiotensin system (RAS) antagonists, diabetic medications, and/or statin medications reported through Healthcare Effectiveness Data and Information Set (HEDIS) Medicare Star Ratings. METHODS: In this retrospective cohort study, data were collected via chart review of pharmacist-led MTM patient interviews and follow-ups between October 2015 and April 2017. Eligible patients were Humana HMO Medicare beneficiaries, with at least one chronic disease state, for which they were treated with a RAS antagonist, statin, or diabetic medication. The primary outcome of this investigation was a change in Star Rating scores for medication adherence to RAS antagonists, diabetic medications, and statins from pre- and postpharmacist MTM intervention. RESULTS: A total of 102 patients were referred to the MTM clinic. Out of these, 32 had a follow-up visit, resulting in a total of 25 interventions. One year prior to MTM clinic implementation, most Star Ratings were consistently 3 (out of 5) for RAS antagonists, diabetic medications, and statins. Postintervention, ratings increased to 4 or 5 across these categories. Conclusion: Implementing a pharmacist-led MTM clinic in the ACO primary care setting improves Medicare Star Ratings in patients with chronic conditions.

Strategies for Managing Pharmacy Experiential Education During COVID-19.

In recent months, the coronavirus pandemic has significantly affected almost every industry in the United States, including health care and higher education. Faculty and students at colleges and schools of pharmacy nationwide have needed to quickly adapt as the delivery of curricula has shifted to primarily online format. Additionally, experiential rotations have been significantly affected as practice settings such as hospitals and outpatient clinics have limited students' interactions with patients or stopped allowing students on-site altogether. Our commentary will explore strategies that have been employed by experiential education coordinators and pharmacy preceptors from various settings to navigate experiential education during these difficult times while ensuring students successfully meet requirements for graduation. These will include descriptions of transitioning advanced pharmacy practice experiences (APPEs) to virtual format, how to safely involve students in the care of COVID-19 patients, and managing scheduling issues.

Development and evaluation of physician-precepted advanced pharmacy practice experiences (APPEs) within an accountable care organization (ACO).

BACKGROUND AND PURPOSE: The American Council of Pharmaceutical Education (ACPE) standards emphasize that pharmacy graduates should be "practice- and team-ready," and the American Society for Health-System Pharmacists (ASHP) Task Force on accountable care organizations (ACOs) states that curricula at pharmacy schools should be evaluated and reworked to prepare students to practice effectively as members of the health care team within ACOs. The objective of this study was to describe the development of an ACO-based advanced pharmacy practice experience (APPE) rotation block, clinical activities and interventions completed by students during the experience, and perceptions of students, patients, and physician preceptors regarding the experience. EDUCATIONAL ACTIVITY AND SETTING: The rotation block was within outpatient ACO offices and consisted of a four-week rotation with one pharmacy faculty, immediately followed by a four-week elective experience in a different office with a physician serving as primary preceptor. FINDINGS: Eight students completed the rotation block between August 2017 and April 2018. Students documented a total of 1299 clinical activities and 65 interventions. Medication reconciliation and recommendations to initiate a medication were the most commonly completed activities and interventions documented. The experience was positively perceived among surveyed students, patients, and physician preceptors. SUMMARY: The rotation block was successfully implemented with a positive response from students, patients, and physician preceptors. As a result, the program has expanded in accordance with ACPE Standards to create "practice- and team-readiness" among graduates and expose students to interdisciplinary care within ACOs and other settings.

Impact of pharmacist-led heart failure tool kits on patient-reported self-care behaviors in a primary care-based accountable care organization.

OBJECTIVE: The goal of this project is to evaluate the impact of a pharmacist-led heart failure (HF) intervention, using an educational toolkit, on patient-reported self-care maintenance, management, and confidence at 30 days. SETTING: Three Accountable Care Organization (ACO) primary care provider offices in South Florida from January to March 2018. PRACTICE DESCRIPTION: Each primary care clinic was staffed with at least 1 physician, nurse practitioners, a clinical pharmacy faculty member, pharmacy residents and students, and ancillary staff. Pharmacists spent approximately 2 days per week in clinic. PRACTICE INNOVATION: At the time of this project, no formalized management program for HF patients existed within the clinics. An educational toolkit was designed, reviewed, and approved by the team of pharmacists and ACO providers before use within the clinics, and included educational material outlining common causes of HF exacerbation, symptoms of HF, symptom management strategies, medication action plan, self-management instructions, medication adherence tips, and a weight-management log sheet. EVALUATION: A prospective, pretest and posttest observational project was conducted at the 3 clinical sites for eligible patients. The Self-Care for Heart Failure Index (SCHFI, v.6.2) tool was used to evaluate self-care practices and adequacy of maintenance, management, and confidence at baseline as compared with 30 days. RESULTS: Twelve participants completed the initial interview and 30-day follow-up. SCHFI scores for self-maintenance (63-68, P = 0.04) and self-management (38-58, P = 0.01) significantly improved from baseline, whereas self-confidence scores showed an increase, but was not statistically significant (80-82, P = 0.58). All self-care behaviors saw a nonstatistically significant improvement in percentage of patients achieving adequacy. CONCLUSION: Pharmacists and educational toolkits in the ACO primary care setting may improve self-maintenance, self-management, and self-confidence behaviors in patients with HF.

Chronic Obstructive Pulmonary Disease and Heart Failure Self-Management Kits for Outpatient Transitions of Care.

OBJECTIVE: To develop heart failure (HF) and chronic obstructive pulmonary disease (COPD) self-management kits in an accountable care organization (ACO) to facilitate patients' self-care and prevent hospital readmissions. SETTING: Pharmacists practice in an outpatient-based ACO. They participate in interprofessional office visits with providers and independently manage maintenance pharmacotherapies. PRACTICE DESCRIPTION: Pharmacists collaborate with an interprofessional team within the ACO including physicians, nurses, case managers, and paramedics. Two commonly encountered diseases are chronic COPD and HF. Reducing preventable readmissions for these conditions are important quality benchmarks and cost-saving strategies. PRACTICE INNOVATION: Pharmacists were responsible for developing HF and COPD self-management kits containing patient education materials and prescriptions to facilitate self-care. Prior to kit development, pharmacists performed a literature review to determine the presence of previously published findings on these topics. MAIN OUTCOME MEASUREMENTS: The interprofessional team continually evaluates the successes and limitations of this initiative. Pharmacists developed training and instructions for ACO allied health professionals in an effort to incorporate the self-management kits in clinical practice. RESULTS: The initial literature search revealed no studies describing the intervention of interest. Innovative programs designed to help reduce preventable readmissions are lacking in primary care. Implementation of the self-management kits was accepted by interprofessional ACO leadership and is currently being integrated into allied health workflow. CONCLUSION: Patients at risk for having an exacerbation of COPD or HF should receive self-management strategies. Prompt therapy prior to exacerbations reduces hospital admissions and readmissions, speeds recovery, and slows disease progression. Pharmacist-facilitated implementation of self-management kits may be developed by interprofessional health care teams.

Evaluation of Early Versus Late Postdischarge Medication Reconciliation on Readmission Rates and Emergency Department Visits.

BACKGROUND: The current literature speculates ideal postdischarge follow-up focusing on transitions from hospital to home can range anywhere between 48 hours and 2 weeks. However, there is a lack of evidence regarding the optimal timing of follow-up visit to prevent readmissions. OBJECTIVE: The purpose of this study is to evaluate the impact of early (<48 hours) versus late (48 hours-14 days) postdischarge medication reconciliation on readmissions and emergency department (ED) use. METHODS: In this retrospective study, data for patients who had a clinic visit with a primary care provider (PCP), clinical pharmacist, or both for postdischarge medication reconciliation were reviewed. Primary outcome included hospital use rate at 30 days. Secondary outcomes included hospital use rate at 90 days and hospital use rate with a postdischarge PCP follow-up visit, clinical pharmacist, or both at 30 days. RESULTS: One hundred sixty patients were included in the analysis: 31 early group patients and 129 late group patients. There was no significant difference on hospital use at 30 days in patients who received early or late groups (32.3% vs 21.8%, P = .947). There was also no significant difference on hospital use at 90 days in patients in early versus late group (51.6% vs 50.3%, P = .842). The type of provider (PCP vs pharmacists) conducting postdischarge medication reconciliation did not show significance on hospital use at 30 days (19.9% vs 21.4%, P = .731). CONCLUSION: Results from this study suggest patients can be seen up to 14 days postdischarge for medication reconciliation with no significant difference on hospital use.

Integration Strategies of Pharmacists in Primary Care-Based Accountable Care Organizations: A Report from the Accountable Care Organization Research Network, Services, and Education.

BACKGROUND: The accountable care organization (ACO) is an innovative health care delivery model centered on value-based care. ACOs consisting of primary care providers are increasingly becoming commonplace in practice; however, medication management remains suboptimal. PROGRAM DESCRIPTION: As experts in medication management, pharmacists perform direct patient care and assist in the transition from one provider to another, which places them in an ideal position to manage multiple aspects of patient care. Pharmacist-provided care has been shown to reduce drug expenditures, hospital readmissions, length of stay, and emergency department visits. Although pharmacists have become key team members of interdisciplinary teams within traditional care settings, their role has often been overlooked in the primary care-based ACO. In 2015, Nova Southeastern University College of Pharmacy founded the Accountable Care Organization Research Network, Services, and Education (ACORN SEED), a team of pharmacy practice faculty dedicated to using innovative approaches to patient care, while providing unique learning experiences for pharmacy students by partnering with ACOs in the South Florida region. Five opportunities are presented for pharmacists to improve medication use specifically in primary care-based ACOs: medication therapy management, annual wellness visits, chronic disease state management, chronic care management, and transitions of care. OBSERVATIONS: Several challenges and barriers that prevent the full integration of pharmacists into primary care-based ACOs include lack of awareness of pharmacist roles in primary care; complex laws and regulations surrounding clinical protocols, such as collaborative practice agreements; provider status that allows compensation for pharmacist services; and limited access to medical records. By understanding and maximizing the role of pharmacists, several opportunities exist to better manage the medication-use process in value-based care settings. IMPLICATIONS/RECOMMENDATIONS: As more organizations realize benefits and overcome barriers to the integration of pharmacists into patient care, programs involve pharmacists will become an increasingly common approach to improve outcomes and reduce the total cost of care and will improve the financial viability of primary care-based ACOs. DISCLOSURES: No outside funding supported this research. The authors report no conflicts of interest related to this manuscript. Study concept and design were contributed by Joseph, Hale, and Eltaki, with assistance from the other authors. Prados and Jones took the lead in data collection and data interpretation and analysis, with assistance from the other authors. The manuscript was written primarily by Joseph and Hale, along with the other authors, and revised primarily by Seamon and Gernant, along with the other authors.

Elevated International Normalized Ratio in a Patient Taking Warfarin and Mauby: A Case Report.

We describe a 70-year-old Haitian man who had been taking warfarin for 5 years for atrial fibrillation and pulmonary hypertension. This patient had his international normalized ratio (INR) checked in the pharmacist-run anticoagulation clinic and was followed monthly. Prior to the interaction, his INR was therapeutic for 5 months while taking warfarin 10.5 mg/d. The patient presented with an INR > 8.0. Patient held 4 days of warfarin and restarted on warfarin 8.5 mg/d. Two weeks later, his INR was 2.5. After continuing dose, patient presented 2 weeks later and INR was 4.8. Upon further questioning, the patient stated he recently began ingesting mauby. Mauby is a bitter dark liquid extracted from the bark of the mauby tree that is commonly used in the Caribbean population as a folk remedy with many health benefits. This case report illustrates that mauby may have a probable drug-herb interaction (Naranjo Algorithm Score of 6) when given with warfarin. There is a lack of published literature and unclear information on the Internet describing the interaction of mauby and warfarin. Health professionals should be cautious regarding interactions between warfarin and mauby until the interaction is fully elucidated.

Current analysis of women athletes with pelvic pain.

BACKGROUND AND METHODS: Accurate diagnosis and effective management of pelvic pain in women have become more challenging now that the number of women athletes and the number of diagnostic possibilities are increasing. We conducted a prospective study of women athletes with pelvic pain seen during a 2-yr period within a large well-defined clinical practice to clarify some of the current causes and treatment possibilities. RESULTS: One hundred fourteen females, 14% of the total male/female cohort, were referred for treatment of suspected musculoskeletal injury. On the basis of history and physical and radiological examinations, 74 (64.9% of females) turned out to have injuries of the hip (group A) and/or soft tissues surrounding the hip (group B), and 40 (35.1%) had other sometimes more threatening diagnoses. In groups A and B, 40 (90.1%) of 44 patients who chose surgery achieved previous performance levels within 1 yr compared with only 4 (13.8%) of 29 who did not have surgery. Factors such as sport type, competitive status, and age did not affect the outcomes. Most diagnoses in group C, e.g., inflammatory bowel disease, reflex sympathetic dystrophy, and malignancy, usually eclipsed the potential musculoskeletal diagnoses in terms of long-term importance. CONCLUSIONS: In this series of patients, most pelvic pain in women athletes was identifiable and treatable. Most had benign musculoskeletal causes, and surgery played an important role in treatment of those causes. Still, we found a large number of other causes that required longer specialized care. Health care professionals seeing such patients need to be alert to the new concepts of pelvic injury and the various roles for surgery and the broad list of other considerations.