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The Discharge Companion Program: An Interprofessional Collaboration in Transitional Care Model Delivery

Authors
  • Bingham, Jennifer1
  • Campbell, Patrick
  • Schussel, Kate1
  • Taylor, Ann M.2
  • Boesen, Kevin
  • Harrington, Amanda
  • Leal, Sandra1
  • Warholak, Terri2
  • 1 (S.L.)
  • 2 (T.W.)
Type
Published Article
Journal
Pharmacy: Journal of Pharmacy Education and Practice
Publisher
MDPI
Publication Date
Jun 19, 2019
Volume
7
Issue
2
Identifiers
DOI: 10.3390/pharmacy7020068
PMID: 31248090
PMCID: PMC6631279
Source
PubMed Central
Keywords
License
Green

Abstract

To reduce readmission rates and avoid financial penalties from the Centers for Medicare and Medicaid Services, hospitals are seeking to implement innovative transitions of care (TOC) programs. This retrospective study evaluated the Discharge Companion Program (DCP), a pharmacist- and nurse-coordinated interprofessional, collaborative TOC program. Adult patients (18 years and older) from a single hospital, discharged with at least one qualifying diagnosis, were eligible for this service. The hospital transitional care coordinator nurse referred qualified patients to the DCP nurse coordinator, who scheduled telephonic medication therapy management (MTM) reviews with the DCP pharmacist at one- and three-weeks postdischarge. Hospital records and DCP documentation were reviewed to describe respective interventions and assess the impact on 30-day readmissions. A total of 456 patients were referred to the DCP between 31 August, 2015 and 7 September, 2016. Of the 340 patients who participated (DCP group), 44 (13%) compared to 17% (n = 20) of the usual care, were readmitted within 30-days postdischarge. The DCP pharmacists conducted 1242 clinical interventions with participants, demonstrating the benefits of an interprofessional TOC model involving multiple, pharmacist-delivered MTM intervention touchpoints within 30 days post-hospital discharge.

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