Transitions of care at an ambulatory care clinic: An implementation science approach

Elizabeth Lieu; Amanda R Mercadante; Emmanuelle Schwartzman; Anandi V Law

doi:10.1016/j.sapharm.2021.06.022

Transitions of care at an ambulatory care clinic: An implementation science approach

Res Social Adm Pharm. 2022 May;18(5):2848-2853. doi: 10.1016/j.sapharm.2021.06.022. Epub 2021 Jun 30.

Authors

Elizabeth Lieu¹, Amanda R Mercadante², Emmanuelle Schwartzman³, Anandi V Law⁴

Affiliations

¹ Western University of Health Sciences: College of Pharmacy, 309 East Second Street 109 A, Pomona, CA, 91766, USA. Electronic address: e_lieu1@u.pacific.edu.
² Western University of Health Sciences: College of Pharmacy, 309 East Second Street 109 A, Pomona, CA, 91766, USA. Electronic address: amandarmerc@gmail.com.
³ Western University of Health Sciences: College of Pharmacy, 309 East Second Street 109 A, Pomona, CA, 91766, USA. Electronic address: eschwartzman@westernu.edu.
⁴ Western University of Health Sciences: College of Pharmacy, 309 East Second Street 109 A, Pomona, CA, 91766, USA. Electronic address: alaw@westernu.edu.

PMID: 34244076
DOI: 10.1016/j.sapharm.2021.06.022

Abstract

Background: Transitions of care (TOC) issues contribute to approximately 76% of preventable hospital readmissions. Centers for Medicare and Medicaid Services (CMS) focus on improvement of quality of care through TOC services. Studies have not used both implementation science and patient input to develop a TOC program that fulfills CMS criteria and satisfies patients' reported needs.

Objectives: The study objectives were to I) develop the TOC program in alignment with CMS criteria, identifying and remedying barriers during the process, and II) conduct a needs assessment and obtain patient perspectives on TOC service.

Methods: The implementation science approach was chosen to refine the TOC service at one university medical center ambulatory care clinic. Barriers within the TOC program that prevented CMS criteria from being followed were identified on site during patient care. Changes were implemented in a timely manner by the pharmacy resident and TOC team. A prospective nine-item open-answer survey was administered to patients discharged less than 90 days from inpatient care. Data was collected, categorized, and presented to the TOC team for incorporation into the TOC service.

Results: Barriers and gaps in care were identified in the sample of 19 patients undergoing service from November 2019 to January 2020. CMS criteria and established TOC protocol had not been fulfilled for all patients. Eight barriers were revealed throughout the TOC process. Solutions were implemented through an in-service, monthly reminders, and communication to staff from the resident pharmacist. Patient responses (n = 22) to the needs assessment indicated a desire for enhanced TOC education (discharge medications and therapy).

Conclusions: Through implementation science, the TOC program was adapted to fulfill CMS criteria and TOC protocol. The needs assessment highlighted desired changes by TOC patients. Long-term outcomes will need to be studied to determine if the implemented changes at this site are sustainable.

Keywords: Ambulatory care; Implementation science; Needs assessment; Patient perspective; Pharmacist role; Transitions of care.

MeSH terms

Aged
Ambulatory Care
Humans
Implementation Science*
Medicare
Medication Reconciliation
Pharmacy Service, Hospital*
Professional Role
Prospective Studies
United States