Pharmacy-led transition of care services with positive readmissions impact in an acute care hospital

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ID: 329479
2026
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Ranked #22 of 247 articles by views in American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists

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Abstract
PURPOSE: To evaluate the impact of pharmacy transitions of care (TOC) services on all cause 30-day readmission rates among Medicare Bundled Payment for Care Improvement Advanced Initiative (BPCI-A, referred to as Bundle) patients. METHODS: This retrospective study included BPCI-A patients discharged from a large academic hospital between July 1, 2023, and June 30, 2024. Pharmacy TOC services included admission medication history, discharge medication review, and pharmacist-led PDFU conducted within 72 hours of discharge. Thirty-day readmission rates were compared between patients receiving comprehensive TOC services versus partial or no TOC, and between patients receiving PDFU versus no PDFU. Multivariable logistic regression and Cox proportional hazards models adjusted for demographic and clinical covariates. RESULTS: Of 6,095 discharged patients, 5,122 were included in the analysis. Patients receiving comprehensive TOC services had lower 30-day readmission rates compared with controls (12.63% vs 17.06%; OR, 0.70; 95% CI, 0.60-0.82; p < 0.05). Patients receiving PDFU also had significantly lower readmissions (12.52% vs 22.54%; OR, 0.49; 95% CI, 0.41-0.59; p < 0.05). In adjusted analyses, both comprehensive TOC (HR, 0.71; 95% CI, 0.61-0.82) and PDFU (HR, 0.49; 95% CI, 0.41-0.58) were associated with reduced hazard of 30-day readmission (p < 0.001 for both). Non-English language and higher discharge medication count were associated with increased readmission risk. CONCLUSION: Pharmacist-managed TOC services, particularly PDFU, were associated with significantly reduced 30-day readmissions among BPCI-A patients, supporting pharmacist involvement in value-based care models.
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Authors Rita Shane, Jackie Ho, Donna Leang, Sarah Stephens, Joshua Pevnick, Hai Tran, Vipul Patel, Steven M. Simons
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Journal American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists
Year 2026
DOI
10.1093/ajhp/zxag291
URL
https://doi.org/10.1093/ajhp/zxag291
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