Transitions of Care Pharmacy Program

About the Program

Category: Health (Best in Category)

Year: 2021

The Los Angeles County Department of Health Services (DHS) Whole Person Care (WPC) Transitions of Care (TOC) Pharmacy Program supports high-risk, medically-complex Los Angeles County residents with medication-related needs as they transition from an inpatient hospital stay to their homes and communities. During this transition period, medication-related problems are common and can result in safety complications and readmissions. Pharmacist-led medication interventions have been shown to improve medication education, reduce medication errors, and even reduce readmissions. In 2020, we designed and implemented a TOC Pharmacy program with clinical pharmacists who had experience working in safety-net clinical settings and/or serving vulnerable patient populations. These 5 clinical pharmacists screened recent inpatient discharges and arranged a follow-up visit to perform interventions such as medication reconciliation and education. From May 1, 2020 through December 31, 2020, there were 5,241 inpatient discharges that met initial screening criteria, and 5,045 (96%) underwent further chart review for full inclusion criteria. There were 3,096 eligible discharges; 100% received outreach attempts, and 2,020 (65%) were successfully reached and received the TOC Pharmacy Intervention. Once available, we will analyze post-intervention utilization and pharmacy claims data to determine the program’s impact on 30-day all-cause readmissions, medication adherence, and engagement in primary care.