pharmacy

Article
Impact of Pharmacist Involvement on Telehealth
Transitional Care Management (TCM) for High
Medication Risk Patients
Jessica Cole *, Nick Wilkins, Maeghan Moss , Danny Fu, Paige Carson and Linda Xiong
Atrium Health Cabarrus Medication Management Clinic, 315 Medical Park Drive NE, Suite 204, Concord,
NC 28025, USA; Nick.Wilkins@atriumhealth.org (N.W.); Maeghan.Moss@atriumhealth.org (M.M.);
Danny.Fu@atriumhealth.org (D.F.); Paige.Carson@atriumhealth.org (P.C.); li.xiong@wingate.edu (L.X.)
* Correspondence: Jessica.Cole@atriumhealth.org




Received: 25 September 2019; Accepted: 21 November 2019; Published: 25 November 2019


Abstract: This pilot study sought to evaluate the impact of pharmacist involvement in the preexisting
telehealth transitional care management (TCM) program at Atrium Health on the quality and safety
of the medication discharge process for high medication risk patients. Eligible participants were those
18 years of age or older with moderate-to-high risk for hospital readmission who were contacted
by a TCM Nurse, identified as high medication risk patients, and referred to the TCM Pharmacist
from September 2018 through February 2019. The TCM Pharmacist contacted patients by phone,
completed a comprehensive medication review, identified medication list discrepancies (MLDs) and
medication-related problems (MRPs), and made interventions or recommendations to primary care
providers. Primary endpoints included the number and types of MLDs identified, number and types
of MRPs identified, and the rate of unplanned 30-day hospital readmissions. Seventy-six patients
were enrolled, and 78 MLDs and 108 MRPs were identified. Of the identified MRPs, 74.1% were
resolved. A relative risk reduction of 36.8% was achieved for 30-day hospital readmissions for those
with high medication risk contacted by the TCM Pharmacist compared to those only contacted by
the TCM Nurse. Overall, TCM Pharmacists identified and resolved 80 medication-related problems,
improved access to medication therapy, provided comprehensive medication counseling, and bridged
gaps in care following hospital discharge.

Keywords: transitional care management; transitions of care; care transitions; medication access;
medication reconciliation; medication management; polypharmacy; hospital readmissions

1. Introduction
The cost of healthcare services in the United States is disproportionately concentrated among a
small percentage of patients with complex health needs [1]. This patient population typically includes
older adults who possess multiple chronic conditions and/or functional limitations [2]. Targeted care
models addressing this risk-stratified patient population can achieve improvement in patient outcomes
and reduce healthcare spending through the utilization of interdisciplinary teamwork, fluid care
transitions, and a standardized medication management process [2].
Transitional care management (TCM) involves services provided to a patient with complex
health needs following discharge from the facility setting [3]. Achieving effective transitions between
healthcare settings is integral in preventing hospital readmissions and ensuring patient safety. Hospital
readmission rates within 30 days have been reported to be as high as 20% for Medicare patients [4].
The rate of hospital readmissions within 30 days has become a standard quality measure, and the
Centers for Medicare and Medicaid Services enact monetary penalties for 30-day hospital readmissions

Pharmacy 2019, 7, 158; doi:10.3390/pharmacy7040158 www.mdpi.com/journal/pharmacy

Pharmacy 2019, 7, 158 2 of 10

in select high-risk disease states [5]. Some common factors impeding effective transitions between care
settings include insufficient patient or caregiver education, a lack of communication between inpatient
and ambulatory care providers, and inadequate assessment of medication access and health literacy
prior to discharge [6]. Medication-related problems (MRPs) such as duplications of drug therapy,
inadequate drug monitoring, and unintentional discontinuation of medications during the hospital
admission process may occur when transitioning from inpatient to outpatient care, as nearly two thirds
of post-discharge adverse events are medication-related [6,7].
Project Re-Engineered Discharge, also referred to as Project RED, determined that patients who
met with a nurse discharge advocate prior to discharge and were contacted by phone by a pharmacist
2–4 days post-discharge had a 30% lower readmission rate within 30 days and a better understanding
of their medications than those who did not receive this service [8]. Similarly, Dempsey et al. identified
244 recommendations for therapeutic optimization and found a 20% reduction in the 30-day hospital
readmission rate for patients with heart failure who met with a transitions-of-care pharmacist before
their outpatient cardiovascular clinic appointment or during the hospitalization [6]. Additionally,
Cavanaugh et al. determined that follow-up with an interdisciplinary team coordinated by a Clinical
Pharmacist Practitioner decreased 30-day hospital readmission rates compared with those who had
follow-up visits with a physician-only team [9]. Finally, Odeh et al. implemented a pharmacist-led
telephonic intervention following hospital discharge and found a 9.9% reduction in 30-day readmission
rates and a 15.2% reduction in 90-day readmission rates compared to patients who did not receive the
service [10]. As medication experts, pharmacists can play a vital role in identifying medication-related
problems, providing medication counseling, ensuring medication access, and facilitating appropriate
outpatient follow-up after hospital discharge in order to improve patient care.
Currently, TCM Nurses at Atrium Health contact moderate-to-high risk discharge patients by
phone to coordinate post-discharge medical appointments and address patient questions. This study
sought to develop a TCM Pharmacist position and evaluate the impact of pharmacist involvement in
the telehealth TCM program on the quality and safety of the medication discharge process for high
medication risk patients.

2. Materials and Methods

2.1. Research Design

The study was designed as a prospective, investigator-initiated pilot study affiliated with Atrium
Health Cabarrus. Atrium Health is a large healthcare network with more than 40 hospitals and 900 care
locations serving patients in Georgia, North Carolina, and South Carolina. Atrium Health Cabarrus
is a 457-bed, not-for-profit medical center located in Concord, North Carolina, United States. The
Institutional Review Board deemed this study a quality improvement project on 24 August 2018. A
postgraduate year-1 pharmacy resident and a team of clinical pharmacists practicing in the ambulatory
care setting at Atrium Health Cabarrus Medication Management Clinic served as the TCM Pharmacist
and conducted the telehealth intervention. A fourth-year student pharmacist monitored by a TCM
Pharmacist assisted with the intervention and data collection.

2.2. Methodology
Eligible participants were those 18 years of age and older with moderate-to-high risk for hospital
readmission who were contacted by a TCM Nurse after hospital discharge from Atrium Health Cabarrus,
identified as high medication risk patients, and referred to a TCM Pharmacist from September 2018
through February 2019. Atrium Health’s electronic health record (EHR) calculates a readmission
risk score based off of the following data: age; body mass index (BMI); insurance; acuity; history of
hospital discharge against-medical-advice (AMA); prior skilled nursing facility admission; emergency
department visit, inpatient admission, or observation stay within the last six months; comorbidity
index; polypharmacy; and high risk medication use. The populated score equates to low (39 or less),
Pharmacy 2019, 7, 158 3 of 10

moderate (40 to 59), or high (60 or more) risk for hospital readmission. Patients classified as moderate
Pharmacy 2019, 7, x FOR PEER REVIEW 3 of 11
or high risk for readmission were automatically added to the TCM Nurse work queue.
Following the
(39 or less), preexisting
moderate workflow,
(40 to 59), or high (60the TCMrisk
or more) Nurse contacted
for hospital patients
readmission. by phone
Patients classifiedwithin 2
businessasdays
moderate or highdischarge
of hospital risk for readmission
to complete wereaautomatically
questionnaire added
whichto the TCM Nurse
evaluated thework queue.
patient/caregiver’s
knowledge Following the preexisting
of the patient’s conditionworkflow, the TCM Nurse
and treatment. Thecontacted patients also
TCM Nurse by phone within warning
discussed 2
business days of hospital discharge to complete a questionnaire which evaluated the
signs/symptoms that require follow-up and reviewed the discharge instructions and discharge
patient/caregiver’s knowledge of the patient’s condition and treatment. The TCM Nurse also
medication list. If
discussed the patient
warning was admitted
signs/symptoms due to
that require chronicand
follow-up obstructive
reviewed thepulmonary disease (COPD),
discharge instructions
diabetesandmellitus,
dischargeheart failure, list.
medication or an acute
If the myocardial
patient infarction
was admitted due to(MI), theobstructive
chronic TCM Nurse asked a preset
pulmonary
list of disease
diseasestate-specific
(COPD), diabetes questions.
mellitus, During the TCM
heart failure, or an Pharmacist
acute myocardialpilot, the TCM
infarction Nurse
(MI), could refer
the TCM
Nurse
the patient to asked
a TCM a preset list of disease
Pharmacist if the state-specific
patient wasquestions.
identified During the TCM
as having Pharmacist
high medicationpilot, risk.
the High
TCM Nurse could refer the patient to a TCM Pharmacist if the patient was identified as having high
medication risk patients were defined as those with polypharmacy (defined as 9 or more medications),
medication risk. High medication risk patients were defined as those with polypharmacy (defined as
medication nonadherence (as identified during the TCM Nurse questionnaire), low medication literacy
9 or more medications), medication nonadherence (as identified during the TCM Nurse
(as determined during
questionnaire), lowthe discharge
medication medication
literacy review),
(as determined highthe
during risk medications
discharge (including
medication review),insulin,
anticoagulants,
high riskand antiplatelet
medications medications),
(including high risk admission
insulin, anticoagulants, diagnoses
and antiplatelet (includinghigh
medications), acuterisk
MI, heart
admission diagnoses
failure, pneumonia, COPD,(including
coronaryacutearteryMI, heart failure,
bypass pneumonia,
grafting (CABG),COPD, coronary
total hip or totalartery
kneebypass
arthroplasty,
grafting (CABG),
and uncontrolled total hip
diabetes), or total
and/or kneespecific
with arthroplasty, andscenarios
clinical uncontrolledat diabetes), and/or of
the discretion with
thespecific
TCM Nurse.
clinical scenarios at the discretion of the TCM Nurse. The TCM Pharmacist referral process is outlined
The TCM Pharmacist referral process is outlined in Figure 1.
in Figure 1.

Moderate-to-high risk discharge patient is added

to TCM Nurse work queue

TCM Nurse contacts patient by phone within

2 business days of hospital discharge

TCM Nurse identifies patient as a high

medication risk patient

TCM Nurse generates TCM Pharmacist referral

TCM Pharmacist contacts patient by phone within

2 business days following referral

FigureFigure 1. Transitional
1. Transitional care
care management (TCM)
management (TCM)Pharmacist
Pharmacistreferral process.
referral process.

The referral was made electronically within the EHR. The TCM Pharmacist monitored the
The referral was made electronically within the EHR. The TCM Pharmacist monitored the referral
referral box on weekdays. When a new patient case was received, the TCM Pharmacist reviewed the
box on weekdays. When a new patient case was received, the TCM Pharmacist reviewed the reason for
reason for referral and documentation from the recent hospitalization. The TCM Pharmacist
referral completed
and documentation
a chart review from
and the recent
began hospitalization.
a comprehensive The TCM
medication reviewPharmacist
by assessing completed
the patient’s a chart
review and
renalbegan a comprehensive
and hepatic medication
function; potential drug–drug review by assessing
interactions, the patient’s
drug–disease renal
interactions, andand
sidehepatic
function;effects; indications
potential for therapy;
drug–drug disease control;
interactions, and insurance
drug–disease coverage.and
interactions, The side
TCM effects;
Pharmacist then
indications for
therapy;contacted the patient
disease control; andbyinsurance
phone within 2 business
coverage. Thedays
TCM of Pharmacist
receiving thethen
referral to address
contacted the any
patient by
medication-related concerns and reconcile the medication list. The TCM Pharmacist completed the
phone within 2 business days of receiving the referral to address any medication-related concerns and
comprehensive medication review during the telephone encounter and identified any medication list
reconcile the medication list. The TCM Pharmacist completed the comprehensive medication review
discrepancies (MLDs) and/or MRPs. The TCM Pharmacist enacted interventions if appropriate;
during the telephone
contacted encounterinsurance
a pharmacy, and identified
company, any medication list discrepancies
or patient assistance program;(MLDs)
and/or and/or
made MRPs.
The TCM Pharmacist enacted
recommendations interventions
to the patient’s primary if
careappropriate;
provider viacontacted a pharmacy,
the EHR messaging systeminsurance company,
or telephonic
interactions.
or patient assistance program; and/or made recommendations to the patient’s primary care provider
via the EHRThe TCM Pharmacist
messaging systemdocumented interventions
or telephonic and time spent on encounters in the PharmD
interactions.
Clinical Interventions Documentation Ad Hoc form and in the patient’s EHR. The PharmD
The TCM Pharmacist documented interventions and time spent on encounters in the PharmD
Interventions Documentation Ad Hoc form is a reporting tool for MRPs created within the EHR
Clinical Interventions Documentation Ad Hoc form and in the patient’s EHR. The PharmD Interventions
Documentation Ad Hoc form is a reporting tool for MRPs created within the EHR following parameters
defined by Crisp and colleagues [11]. A follow-up phone call was completed by a TCM Pharmacist
within 14–21 days after the initial call to ensure MRPs were resolved and no further medication-related
Pharmacy 2019, 7, 158 4 of 10

concerns persisted. If warranted, further documentation was completed in the PharmD Clinical
Interventions Documentation Ad Hoc form and the patient’s EHR.

2.3. Primary and Secondary Endpoints

Primary endpoints included the number and types of MLDs identified, the number and types of
MRPs identified, and the number and rate of unplanned 30-day hospital readmissions. Secondary
endpoints included the number of MRPs resolved, number of recommendations accepted by providers,
number of calls attempted, and number of calls completed. Time to first contact and time spent on the
encounter were also analyzed.

2.4. Data Analysis

A sample size of 95 pairs was determined to detect a 10% reduction in the 30-day hospital
readmission rate between the intervention and control groups and achieve 80% power with an alpha
level of 0.05. Data were collected from the PharmD Clinical Interventions Documentation Ad Hoc form
and the patient’s EHR. Data were stored and analyzed using the Research Electronic Data Capture
(REDCap) database without patient identifiers. Endpoints were analyzed using descriptive statistics,
including counts and percentages. The primary analysis of the 30-day hospital readmission rate
endpoint comparing patients contacted by the TCM Pharmacist and patients who declined services or
could not be reached was evaluated using a two-sided Barnard test. A two-tailed p-value of less than
0.05 was considered statistically significant.

3. Results

3.1. Patient Enrollment

Eighty-nine TCM Pharmacist referrals were obtained from September 2018 through February 2019.
Seventy-six patients
Pharmacy 2019, 7, xwere contacted
FOR PEER REVIEW by the TCM Pharmacist, six patients were not reached,5 six
of 11patients
declined or were no longer interested, and one case was created in error, as depicted in Figure 2.

TCM Nurse contacted patients with moderate-to-high risk for readmission

by phone within 2 business days of hospital discharge

TCM Nurse generated 89 TCM Pharmacist referrals

6 patients declined or
76 patients were 6 patients could not
were no longer 1 case was created in
contacted by TCM be reached by TCM
interested in TCM error
Pharmacist Pharmacist
Pharmacist service

50 patients were reached 26 patients were reached

within 2 business days 3 or more business days
following referral following referral

34 patients were 16 patients were

contacted 14-21 days contacted 14-21 days
following the initial following the initial
telephonic interaction telephonic interaction

Figure
Figure 2. TCMPharmacist
2. TCM Pharmacist patient
patientenrollment.
enrollment.

The average time to initial contact by the TCM Pharmacist was 2.1 business days following
referral. Of the 76 patients contacted by the TCM Pharmacist, 50 were reached within 2 business days
of referral from the TCM Nurse. An additional 8 patients were contacted within 3–4 business days
following referral. Fifteen additional patients were contacted within 10 business days following
referral. Three patients were not reached until 12 or more business days following referral. The range
Pharmacy 2019, 7, 158 5 of 10

The average time to initial contact by the TCM Pharmacist was 2.1 business days following referral.
Of the 76 patients contacted by the TCM Pharmacist, 50 were reached within 2 business days of referral
from the TCM Nurse. An additional 8 patients were contacted within 3–4 business days following
referral. Fifteen additional patients were contacted within 10 business days following referral. Three
patients were not reached until 12 or more business days following referral. The range for time to
initial contact was 0 to 24 business days following referral.

3.1.1. Baseline Characteristics

The average age of patients contacted by the TCM Pharmacist was 65 years old. More than half
were female (59.2%) and Caucasian (77.9%). The three most common comorbidities were hypertension
(73.7%), dyslipidemia (52.6%), and type 2 diabetes mellitus (50.0%). Thirty-two patients (42.1%) were
taking a narcotic or sedative, 30 patients (39.5%) were on anticoagulant therapy, and 24 patients
(31.6%) were using insulin therapy. On average, the patients had nine chronic conditions and 15 active
medications at the time of hospital discharge. The patient population’s baseline demographics are
summarized below in Table 1. Table 1 also includes the baseline characteristics for the 12 individuals
in the Non-TCM Pharmacist Intervention Group who were referred to the TCM Pharmacist but were
not reached or declined the service.

Table 1. Baseline characteristics of Transitional Care Management (TCM) Pharmacist patient population.

TCM Pharmacist Non-TCM Pharmacist

Variable Intervention Group Intervention Group
(n = 76) (n = 12)
Age, years
Mean (Range) 65 (25–88) 61 (38–77)
Sex, n (%)
Female 45 (59.2) 8 (66.7)
Male 31 (40.8) 4 (33.3)
Race, n (%)
African American 14 (18.2) 5 (41.7)
American Indian or Alaska Native 2 (2.6) 0 (0.0)
Asian 1 (1.3) 0 (0.0)
Caucasian 60 (77.9) 6 (50.0)
Unknown 0 (0.0) 1 (8.3)
Insurance, n (%)
Commercial 10 (13.1) 3 (25.0)
Medicaid 11 (14.5) 0 (0.0)
Medicare 42 (55.3) 7 (58.3)
Medicare/Medicaid 7 (9.2) 1 (8.3)
Self-Pay 6 (7.9) 1(8.3)
Medical History, n (%)
Anxiety 26 (34.2) 4 (33.3)
Atrial Fibrillation 21 (27.6) 2 (16.7)
Chronic Kidney Disease 13 (17.1) 5 (41.7)
Chronic Obstructive Pulmonary Disease 26 (34.2) 2 (16.7)
Congestive Heart Failure 24 (31.6) 4 (33.3)
Coronary Artery Disease 26 (34.2) 3 (25.0)
Depression 22 (28.9) 2 (16.7)
Dyslipidemia 40 (52.6) 9 (75.0)
Hypertension 56 (73.7) 8 (66.7)
Obesity 40 (52.6) 5 (41.7)
Type 2 Diabetes Mellitus 38 (50.0) 7 (58.3)
Pharmacy 2019, 7, 158 6 of 10

Table 1. Cont.

TCM Pharmacist Non-TCM Pharmacist

Variable Intervention Group Intervention Group
(n = 76) (n = 12)
High Risk Medication Use, n (%)
Anticoagulants 30 (39.5) 4 (33.3)
Anti-infectives 27 (35.5) 2 (16.7)
Chemotherapy 1 (1.3) 0 (0.0)
Insulin 24 (31.6) 3 (25.0)
Narcotics and Other Sedatives 32 (42.1) 3 (25.0)
Number of Chronic Conditions, n 1
Mean 9.1 8.8
Range 1–22 3–16
Number of Active Medications, n 1
Mean 15.1 12.8
Range 2–29 6–19
ED Visit Within Past 12 Months, n (%) 2 49 (64.5) 6 (50.0)
Average ED Visits Within Past 12 Months,
1.8 (1–19) 1.3 (0–4)
n (Range) 2
Hospitalization Within Past 12 Months,
49 (64.5) 9 (75.0)
n (%) 2
Average Hospitalizations Within Past
1.6 (1–11) 1.1 (0–3)
12 Months, n (Range) 2
1 Count obtained at time of hospital discharge. 2 Prior to hospitalization generating TCM Pharmacist referral.

Pharmacy 2019, 7, x FOR PEER REVIEW 7 of 11

3.1.2. Reason for TCM Pharmacist Referral
3.1.2.most
The Reason for TCM reasons
common Pharmacist
forReferral
TCM Pharmacist referral were medication access, medication
counseling,The and
most medication
common reasons questions,
for TCMfollowed
Pharmacistbyreferral
polypharmacy,
were medicationprescription coordination,
access, medication
counseling, and medication questions, followed by polypharmacy, prescription coordination,
uncontrolled disease state, and nonadherence. Two cases did not include a reason for TCM Pharmacist
uncontrolled
referral. disease included
Eleven referrals state, andmultiple
nonadherence.
reasonsTwo cases did
for referral. Thenot include
specific a reasonoffor
frequency TCM
each referral
Pharmacist referral. Eleven
type is depicted in Figure 3. referrals included multiple reasons for referral. The specific frequency of
each referral type is depicted in Figure 3.

35 32

30

25 22
21
20

15
10
10 7
4
5 2 2

Figure
Figure 3.3.Reason
Reason for
for referral
referral to
toTCM
TCMPharmacist.
Pharmacist.

3.2. Medication List Discrepancies (MLDs)

Seventy-six MLDs were identified through TCM Pharmacist involvement. Forty-four MLDs
were categorized as Addition Errors, where a medication was included on the medication list which
should not have been. Eighteen Omission Errors, where the medication was not on the list but should
have been, were found. Furthermore, 16 Details Errors, where the medication on the list had incorrect
Pharmacy 2019, 7, 158 7 of 10

3.2. Medication List Discrepancies (MLDs)

Seventy-six MLDs were identified through TCM Pharmacist involvement. Forty-four MLDs were
categorized as Addition Errors, where a medication was included on the medication list which should
not have been. Eighteen Omission Errors, where the medication was not on the list but should have
been, were found. Furthermore, 16 Details Errors, where the medication on the list had incorrect or
missing information, were identified.

3.3. Medication-Related Problems (MRPs)

The TCM Pharmacist identified 108 MRPs. A majority were categorized as nonadherence or
medication access issues (54.6%), with 27 of these MRPs being due to medication cost. Sixteen MRPs
were related to suboptimal dosing, duration, frequency, or administration, while 13 MRPs fell under
the category of suboptimal drug. Table 2 depicts the categorization of the 108 MRPs into broad groups
and more specific subtypes.

Table 2. Medication-related problems (MRPs) identified by TCM Pharmacist (n = 108).

Category Frequency
Undertreatment
 Additional Therapy Required 3
 Untreated Medical Condition 5
Suboptimal Dosing, Duration, Frequency, Administration
 Administration Not Ideal/Correct 3
 Doses Too Low 6
 Doses Too High 7
Monitoring Needed
 Assess/Prevent Potential Adverse Drug Event 7
Suboptimal Drug
 Generic Alternative Available 1
 Safer Alternative Available 1
 No Indication or Need for Therapy 2
 Not Effective/Not Ideal 2
 Potential for Drug Interaction 3
 Therapeutic Duplication 4
Adverse Drug Event Present
 Moderate 1
 Severe 4
Nonadherence/Medication Access Issues
 Fear of Adverse Events 1
 Disbelief in Drug Effectiveness/Indication 2
 Forgets/Too Busy/Not a Priority 2
 Regimen Too Complex 2
 Felt Worse/Minor Side Effects 3
 Other 3
 Patient Not Aware of Medication Changes 4
 Misunderstood Directions 15
 Too Expensive 27

Of the 108 MRPs identified, 49 MRPs were resolved directly by the TCM Pharmacist through
medication counseling, patient education, referral to financial resources, and/or by practicing under
North Carolina’s Clinical Pharmacist Practitioner (CPP) act [12]. Forty-seven recommendations were
made to primary care providers, with 31 recommendations being accepted and implemented. Of the
remaining 28 MRPs which were not resolved, 16 were due to the primary care provider not accepting
the recommendation and 12 were due to the patient not accepting or implementing the TCM Pharmacist
intervention. Overall, 80 MRPs, or 74.1%, of the MRPs identified were resolved.
Pharmacy 2019, 7, 158 8 of 10

3.4. Unplanned 30-Day Hospital Readmission Rate

Of the 76 patients contacted by the TCM Pharmacist, 12 patients were readmitted for an unplanned
hospitalization and one patient was readmitted for a planned procedure at an Atrium Health facility
within 30 days of hospital discharge. Five patients were seen under observation, and eight patients
visited the emergency department at an Atrium Health facility within the 30-day period following
hospital discharge.
Of the six patients who were not reached and the six patients who declined TCM Pharmacist
involvement, three patients were re-hospitalized for an unplanned hospitalization within 30 days
of hospital discharge at an Atrium Health facility. Table 3 depicts the readmission rates for the two
groups and demonstrates a relative risk reduction of 36.8% for those contacted by the TCM Pharmacist
service compared to those who were not reached or declined the TCM Pharmacist service.

Table 3. Unplanned 30-day hospital readmission rate 1 for patients initially referred to TCM
Pharmacist service.

Unplanned 30-Day Readmission Rate

p-Value
Hospital Readmission (n) (%)
Patients Contacted by TCM
Pharmacist Service 12 15.8 0.529
(n = 76)
Patients Not Reached/Declined
TCM Pharmacist Service 3 25.0
(n = 12)
1 At an Atrium Health facility.

3.5. Additional Secondary Endpoints

The TCM Pharmacist attempted 249 calls to the 89 patients referred to the service. Eighty-five
initial or action calls were completed to the 76 patients contacted. Fifty-six follow-up calls were
completed to assess the resolution of MRPs.
For the 76 patients reached by the TCM Pharmacist, 3712 min were spent on the TCM Pharmacist
encounter, including the time spent conducting a chart review, contacting the patient, and intervening
on identified MRPs and MLDs. The average TCM Pharmacist encounter time was approximately
49 min. The median amount of time spent on a TCM Pharmacist encounter was 42 min.

4. Discussion
As evident from the baseline characteristics, the patient population referred to the TCM Pharmacist
service consisted of patients with multiple chronic conditions and complex medication regimens. TCM
Pharmacists identified over 100 MRPs affecting the quality and safety of medication therapy following
hospital discharge for 76 patients with moderate or high risk for hospital readmission and high
medication risk. TCM Pharmacists independently resolved a majority of the MRPs identified through
comprehensive medication counseling, patient/caregiver education, referral to financial resources,
and/or by practicing under the CPP act. Through these interventions, TCM Pharmacists improved
access to medication therapy, clarified complex medication regimens, answered medication- and
disease-related questions, and addressed nonadherence post-discharge through telehealth services.
Within Surbhi et al., the frequency and type of medication therapy problems and discrepancies
were investigated for high healthcare utilizers [13]. The estimated cost avoidance per each drug
therapy problem identified was also evaluated and determined to be $293.30 [13]. As such, the 108
MRPs identified by TCM Pharmacists during the pilot study equates to an estimated cost avoidance of
$31,676.40. Ultimately, utilization of the TCM Pharmacist position allowed for medication optimization
post-discharge and potential cost avoidance.
Pharmacy 2019, 7, 158 9 of 10

Although statistical significance between those contacted by the TCM Pharmacist and those
who declined services or could not be reached was not achieved, the 30-day readmission rate of
15.8% for patients contacted by the TCM Pharmacist was lower than the readmission rate of 17.8%
reported for Medicare beneficiaries in 2012 [14]. As previously highlighted, a majority of the patient
population contacted by the TCM Pharmacist consisted of Medicare beneficiaries. As such, pharmacist
involvement in TCM services could lead to reductions in 30-day readmission rates, although further
analysis is required.
The study should be interpreted while considering the following limitations. Firstly, the pilot study
had a small sample size and did not reach the enrollment necessary to reach 80% power. Additionally,
a comparable control group of adequate size was not identified and limited any potential for statistical
analysis between the control and treatment group. Furthermore, the baseline characteristics between
the control and treatment group were not balanced, and additional analysis to control for confounding
variables is necessary. Due to limited TCM Pharmacist availability, only TCM Nurses serving Atrium
Health Cabarrus were able to refer patients to the TCM Pharmacist service. Also, the referrals were
dependent on the TCM Nurses identifying and referring patients who would benefit from TCM
Pharmacist intervention. Lastly, the readmission data was limited, as only access to Atrium Health
facility data was available.
Moving forward, additional staff will be trained to serve as the TCM Pharmacist at Atrium Health
Cabarrus Medication Management Clinic. If additional resources and pharmacist time is designated to
the TCM Pharmacist service, pharmacist involvement in the TCM program will be expanded to cover
additional hospitals within the Atrium Health system. Additionally, grant funding opportunities are
currently being pursued to support the expansion and continuation of the TCM Pharmacist service.

5. Conclusions
Overall, pharmacist involvement in the telehealth transitional care management program improved
the quality and safety of the medication discharge process for high medication risk patients through
the identification and resolution of 80 medication-related problems.

Author Contributions: Conceptualization, P.C., D.F. and N.W.; methodology, J.C., D.F., M.M. and N.W.; formal
analysis, J.C. and L.X.; investigation, J.C., D.F. and M.M.; writing—original draft preparation, J.C.; supervision,
P.C.; writing—review & editing, J.C., M.M., D.F., N.W., P.C., L.X.
Funding: This research received no external funding.
Acknowledgments: The co-investigators would like to extend a special thank you to Meg Conger; Rachel
Randolph; and Laura Skaff for their involvement as the TCM Pharmacist.
Conflicts of Interest: The authors declare no conflicts of interest.

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