ASHP Best Practices Award Mortar and Pestle

Award Information

Advancing Pharmacy Practice through an Innovative Ambulatory Care Transitions Program

Jamie J. Cavanaugh, Pharm.D., CPP, BCPS, Emily M. Hawes, Pharm.D., BCPS, CPP, Nicole R. Pinelli, Pharm.D., M.S., CDE, Stephen F. Eckel, Pharm.D., M.H.A., BCPS, Michael P. Pignone, M.D., Mark D. Gwynne, D.O., Rowell Daniels, Pharm.D., M.S.


University of North Carolina Health Care, Chapel Hill, North Carolina

Hospital readmissions are common, with an estimated 19.6% of Medicare patients readmitted to the hospital within 30 days.1 The purpose of this project was to 1) develop an interdisciplinary, outpatient clinic-based care transition intervention aimed at reducing 30-day hospital readmission rates, 2) examine the impact of this intervention on clinical, organizational, and financial outcomes, and 3) describe the significance of this program.

The program started in our Internal Medicine Clinic (IMC) with an interdisciplinary team consisting of pharmacists, physicians, care managers, support staff, clinic management, and hospital quality improvement representatives. Eligible patients were scheduled for a clinical pharmacist visit within 14 days of discharge.2 Key features of the visit included medication management using a collaborative practice agreement, identification of medication related problems using medication reconciliation, medication education using teach-back methodology, identification of patient self-reported reasons for hospital admission, identification of barriers to care, assistance with referral to support services, and documentation for continuity of care.

The IMC program has been in place for over two years (March 2012 - present). Compared to usual care, the program decreased the median time to IMC or any clinic follow-up by 5 and 4 days, respectively. The program reduced all cause 30-day hospital readmission rates (9% vs. 26% usual care) and the composite endpoint of 30-day health care utilization, defined as readmission and ED rates, (19% vs. 44% usual care). One 30-day hospital readmission was prevented for every 7 patients seen in follow up clinic equating to 102 per year with an estimated cost reduction of $1,113,000.3 The IMC pharmacist collaborated with the Family Medicine (FMC) pharmacist to standardize pharmacy interventions between practices. In the FMC, the hospital readmission rate was reduced from 20% to 6.5% for patients seen by a clinic-based pharmacist.

We demonstrated a consistent, recognizable contribution from pharmacists providing direct patient care and practicing in the ambulatory care setting that has been replicated across other hospital clinics at our institution. It is a model that can be adopted by other health-systems and hospitals to reduce readmissions.

1. MedPAC. Payment Policy for Inpatient Readmissions. Report to the Congress: reforming the delivery system. Washington, DC: Medicare Payment Advisory Commission; 2007.
2. Cavanaugh JJ, Jones CD, Embree G et al. Implementation Science Workshop: primary care-based multidisciplinary readmission prevention program. J Gen Intern Med. 2014 29:798-804.
3. Centers for Medicare and Medicaid Services. Inpatient Charge Data FY 2012.