JHQ 304: Clinical Pharmacist Transition of Care Model Improves Hospital System Practice by Reducing Readmissions-JHQ 304 Article

JHQ 304 Article

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This article evaluates a pharmacist-led inpatient transitions of care (IPTC) program designed to reduce 30-day hospital readmissions driven by medication-related problems (MRPs), which are especially common in polypharmacy patients. Polypharmacy increases risks such as prescribing errors, adherence issues, adverse drug reactions, and post-discharge medication discrepancies, all of which can contribute to preventable readmissions—an issue heightened in safety-net hospitals serving vulnerable populations with limited resources and significant social determinants of health barriers.<br /><br />Over 16 months at a large public safety-net academic hospital, the program targeted medicine-service inpatients with 10 or more home medications (n=536). These patients received a standardized pharmacist-led bundle: medication admission history interview, medication reconciliation, inpatient medication consultation/education, and a structured phone follow-up 48–72 hours after discharge to confirm medication access, review instructions and side effects, reinforce refills, and ensure follow-up appointments. Patients admitted during the same period with fewer than 10 home medications served as controls receiving usual care (n=2317).<br /><br />The intervention group had a significantly lower 30-day readmission rate (8.8%) than controls (12.4%), representing a 33% lower likelihood of readmission (OR 0.67, 95% CI 0.49–0.94). The reduction was more pronounced among men. Every polypharmacy patient had at least one medication discrepancy, averaging 2.24 discrepancies per patient; the most frequent were duplicate medication orders, followed by medication order status errors and omitted medications.<br /><br />The authors conclude that a comprehensive pharmacist-led TOC approach, even in a resource-limited safety-net setting and supported by pharmacy students, can improve medication safety and meaningfully reduce all-cause 30-day readmissions by identifying and resolving MRPs across multiple transition points.

Keywords

pharmacist-led transitions of care

inpatient transitions of care program

30-day hospital readmissions reduction

medication-related problems (MRPs)

polypharmacy patients

medication reconciliation

medication discrepancies

safety-net hospital

post-discharge phone follow-up

medication safety and adherence