Category: Federal Forum Posters
Purpose: Studies have shown that timely and effective follow-up in the ambulatory care setting is associated with fewer hospitalizations related to ambulatory care sensitive conditions. With a steadily increasing trend in readmission rates, the prevention of hospital readmissions related to heart failure (HF) and chronic obstructive pulmonary disease (COPD) has become a local priority at the Central Arkansas Veterans Healthcare System (CAVHS). The objective of this study is to evaluate the efficacy of post-discharge telephone follow-up provided by ambulatory care pharmacists in a transitions of care (TOC) clinic on 30-day readmissions and ED visits related to HF and COPD.
Methods: This study will be submitted to the Institutional Review Board for approval. Patients with a primary inpatient diagnosis of HF or COPD will be offered close follow-up in the TOC clinic. If patients are agreeable, they will be referred to the pharmacy residents for enrollment into the TOC clinic. To meet inclusion criteria, patients must schedule their first follow-up within 2 weeks of discharge. Pharmacy residents in the TOC clinic will complete 2 telephone follow-ups within 4 weeks of discharge to re‐educate, assess symptoms, and confirm compliance. The exclusion criteria includes patients with cognitive impairment, patients followed by non-VA primary care or specialty services, discharge to another institution or hospice care, home based primary care, discharge AMA, and patient refusal during pre-discharge planning. The following data will be collected: age, gender, weight, smoking status, location of primary care provider, diagnosis, and dates of discharge, pharmacist follow up appointments, and readmission. If applicable, the following data will also be collected: type of heart failure, ejection fraction, NYHA class, GOLD COPD category, mMrc score, and adherence to medication regimen. After 3, 6, and 9 months of clinic establishment, an analysis of 30-day readmission rates and ED visits will be performed.
Results: not applicable
Conclusion: not applicable
Jelena Stojakovic– PGY2 Ambulatory Care Pharmacy Resident, Central Arkansas Veterans Healthcare System, Hot Springs, AR