Category: Federal Forum Posters
Purpose: The Indianapolis VAMC implemented a pharmacist-based quality improvement project focusing on care transitions and identification of ambulatory care sensitive conditions in 2017. The six-month pilot project showed a positive trend towards decreased readmissions, ED-visit rates, and significant ambulatory care medication interventions by pharmacists. This led to practice change at the local facility level and was adopted into standard workflow. The goals of the next phase of this project are to build upon the trend of positive outcomes and overcome barriers encountered in the pilot project through streamlining the referral process, enhancing education to staff, and expansion of clinical pharmacy services.
Methods: The role of the acute care pharmacist includes a complete medication reconciliation on every patient prior to discharge. During this process, at-risk patients, defined as those with uncontrolled ambulatory care sensitive conditions, those in need of an extensive medication reconciliation, or those that have difficulties with adherence, are identified by the pharmacist. The patients are offered additional follow-up from a pharmacist in their clinic and information about the patient is then entered into the hand-off tool. The hand-off tool includes information about the patient’s primary care doctors, and an area for free texting specific concerns about the patient. The ambulatory care pharmacists then have the task to follow-up, by phone, with the identified patients within seven days after discharge. During this phone appointment the pharmacist does a comprehensive medication reconciliation, assessment of adherence and proper device technique, manage chronic conditions, and address any acute concerns. In order to improve utilization of the tool, educational sessions were provided to clinical pharmacy staff and the discharge note template used by acute care pharmacists was also edited to include a prompt for patient inclusion into the program.
Results: not applicable
Conclusion: not applicable
Andrea Dawson– PGY2 Ambulatory Care Pharmacy Resident, Richard L. Roudebush VA Medical Center, Indianapolis, IN