4. Guidelines for
follow-up care
The Institute for Healthcare Improvement Triple Aim
The American Heart Association
American College of Cardiology
5. Use of
Pharmacists
for reducing
readmissions
Addition of a pharmacist to transitions of care programs
Pharmacists help promote medication adherence
Use of pharmacy students to provide telephone follow-up within
7-14 days to provide medication information.
Increased opportunity for ambulatory care pharmacist to be
integrated into primary care teams
Bridge gaps not covered by hospital-based programs
8. Discussion
What is your recommended follow-up time frame for your
discharged HF patients?
Do you perform follow-up telephone calls?
At what time intervals?
What is your transition of care protocol?
Do you have criteria for a follow-up visit to a cardiologist?
If they are scheduled with their primary care physician, how do
you know follow-up has occurred?
9. Discussion
Do you utilize a pharmacist or pharmacy students for
Medication education?
Medication reconciliation?
Follow-up telephone calls?
What criteria do you use to determine post-acute care placement?
Who is on your multidisciplinary team?
Does the team meet on a regular basis to review cases?
How is communication handled so everyone has the same
information, including the patient?
What type of data do you track?
10. NextSteps
Next CHF Workgroup:Thursday, April 9th 2:00 pm to 3:30 pm
Deliverable &Topic: Ronnie Richards will discuss Holland
Hospitals Heart Failure Clinic.
11. Resources
McKay, C. et al., Systematic Review and Meta-analysis of Pharmacist-Led
Transitions of Care Services on the 30-Day All-Cause Readmission Rate of
Patients withCongestive Heart Failure. Clinical Drug Investigation 39 703-712
(2019) https://link.springer.com/article/10.1007/s40261-019-00797-2
Slazak, E. et al., Pharmacist-led transitions-of-care services in primary care
settings: Opportunities, experiences, and challenges. Journal of theAmerican
Pharmacists Association (2019) https://doi.org/10.1016/j.japh.2019.11.016
Murphy, J. A, et al. Implementation of a CardiacTransitions of Care Pilot
Program:A ProspectiveStudy of Inpatient andOutpatientClinical Pharmacy
Services for PatientsWith Heart Failure Exacerbation or Acute Myocardial
Infarction. Journal of Pharmacy Practice (2017)
https://doi.org/10.1177%2F0897190017743129
Neu, R. et al., Impact of Pharmacist Involvement in Heart FailureTransition of
Care. Annals of Pharmacotherapy (2019)
https://doi.org/10.1177%2F1060028019882685
Plakogiannis, R. et al., Impact of PharmacyStudent–Driven Post-discharge
TelephoneCalls on Heart Failure Hospital Readmission Rates:A Pilot Program.
Hospital Pharmacy. (2018) https://doi.org/10.1177%2F0018578718769243