A Pharmacist-led Transitions of Care Program

Study Overview
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Brief Summary
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This study was to show the value of pharmacists in providing transitions of care to and improving health outcomes of uninsured populations. It also aimed to demonstrate the feasibility of implementing a transitions of care program in an indigent care clinic with limited resources. We hypothesized that a pharmacist-led transitions of care program will reduce 30-day hospital readmission rates among the uninsured discharged from a community hospital.

Official Title
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The Impact of a Pharmacist-Led Transitional Care Program on Health Outcomes of Uninsured Populations

Conditions
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Chronic Disease

Intervention / Treatment
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* Behavioral: Transitions of care


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Aged 18 years old or older Uninsured English speaking Discharged from East Alabama Medical Center within the past 16 days Exclusion Criteria: Patients who did not show up for the first follow-up visit with the study pharmacist after being referred by the care coordinator at East Alabama Medical Center

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Transitions of care<br>The study participants in this aim received usual care plus medication reconciliation, daily schedule for medication taking and medical condition monitoring, and follow-up phone calls from a pharmacist. | Behavioral: Transitions of care<br>* The intervention was a pharmacist-led transitions of care program that include medication reconciliation, daily schedule for medication taking and medical condition monitoring, and follow-up phone calls from a pharmacist at 60- and 90-day post-discharge in addition to the usual care.<br>|
| No Intervention: Usual care<br>The study participants in this arm received usual care. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 30-day hospital readmission | Whether a study participant had any hospital readmission 30-day post-discharge | 30-day post-discharge | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 60-day hospital readmission | Whether a study participant had any hospital readmission 60-day post-discharge | 60-day post-discharge | 
| 90-day hospital readmission | Whether a study participant had any hospital readmission 90-day post-discharge | 90-day post-discharge | 
| 30-day emergency department (ED) visit | Number of ED visits among study participants in each study arm 30-day post-discharge | 30-day post-discharge | 
| 60-day emergency department (ED) visit | Number of ED visits among study participants in each study arm 60-day post-discharge | 60-day post-discharge | 
| 90-day emergency department (ED) visit | Number of ED visits among study participants in each study arm 90-day post-discharge | 90-day post-discharge | 
| 30-day follow-up visit with a primary care provider | Did a study participant keep a follow-up appointment with a primary care provider | 30-day post-discharge | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Transitions of care, Indigent population, Hospital readmission rates