Heart Failure Transitions of Care: A Pharmacist-Led Post-Discharge Pilot Experience

Objective To perform a pilot evaluation of a pharmacist-led, multidisciplinary transitional care clinic for heart failure (HF) patients. Background Transitions of care in HF should include: medication reconciliation, multidisciplinary care, early post-discharge follow-up, and prompt intervention on HF signs and symptoms. We hypothesized that combining these elements with optimization of medications would impact outcomes. Methods In the SERIOUS HF Medication Reconciliation Transitional Care Clinic (HF MRTCC), patients were seen by a clinical pharmacist trained in HF. The pharmacist performed medication reconciliation, a basic physical exam, and a HF symptom history. Medications were adjusted by the clinical pharmacist or medical provider. Data were retrospectively collected for a quality improvement evaluation of this novel clinic on medication discrepancies, medications optimized, and 30-day readmissions. Descriptive statistics and paired t-tests were used for medication doses. Results All patients (n = 135) had a diagnosis of HF, 59% were recently discharged. The mean time from discharge to the clinic appointment was 10 ± 6 days, and the 30 day all-cause readmission rate was 9%. Medication discrepancies were detected in 53% of patients. Medications were optimized in 70%, most frequently beta blockers, ace inhibitors, and diuretics. In patients with an ejection fraction ≤ 40%, significantly higher doses of beta blockers and ace inhibitors were prescribed after the clinic visit. Conclusion The HF MRTCC identified and corrected numerous medication discrepancies, up-titrated medications, and was associated with a 30-day readmission rate of 9%. These encouraging pilot results are hypothesis-generating and warrant further controlled trials.