Enhancing Clinical Pharmacy Specialist Involvement in Transitions of Care Focusing on Ambulatory Care Sensitive Conditions within a Veterans Affairs Healthcare System

The purpose of this quality improvement project was to evaluate the impact of clinical pharmacy specialist (CPS) involvement in the post-discharge period on 30-day readmission rates within a Veterans Affairs Healthcare System. Patients eligible for inclusion were discharged from a Veterans Affairs (VA) acute care facility with a principle or secondary diagnosis of heart failure (HF), chronic obstructive pulmonary disease (COPD), or both HF and COPD from 15 October 2018 through 14 January 2019. CPSs functioning as a mid-level provider with a scope of practice conducted telephone and in-clinic medication management appointments within 7 and 21 days post-discharge for qualifying patients discharged with a principle or secondary diagnosis of HF or COPD. CPS appointments focused on medication reconciliation, ensuring continuity of care, disease state counseling, and medication management. By enhancing the role of the CPS in the post-discharge period, there was an observed decrease in 30-day COPD index (<i>p</i> = 0.35), HF index (<i>p</i> = 0.23), and all-cause (<i>p</i> = 0.62) readmission rates from pre- to post-intervention. The results of this intervention show that CPS intervention in the post-discharge period may reduce index and all-cause readmission rates for patients discharged with a principle or secondary discharge diagnosis of COPD or HF.