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The American Journal of Managed Care February 2015
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A Multidisciplinary Intervention for Reducing Readmissions Among Older Adults in a Patient-Centered Medical Home
Paul M. Stranges, PharmD; Vincent D. Marshall, MS; Paul C. Walker, PharmD; Karen E. Hall, MD, PhD; Diane K. Griffith, LMSW, ACSW; and Tami Remington, PharmD
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A Multidisciplinary Intervention for Reducing Readmissions Among Older Adults in a Patient-Centered Medical Home

Paul M. Stranges, PharmD; Vincent D. Marshall, MS; Paul C. Walker, PharmD; Karen E. Hall, MD, PhD; Diane K. Griffith, LMSW, ACSW; and Tami Remington, PharmD
A collaborative practice model to reduce hospital readmissions from an outpatient environment.
A PCMH-based, post hospital discharge intervention utilizing a clinical pharmacist, social worker, and medical provider may reduce readmission rates among older patients when performed soon after discharge; however, the effectiveness is dependent on completing the intervention. Further research is needed to study outcomes of similar programs. These results are most applicable to a PCMH focused on the care of older patients. Resources to implement a multidisciplinary intervention may not be available in all clinic settings, and the current study is unable to determine if certain elements were more important than others in improving outcomes; future study is necessary. Nonetheless, this serves as an example of how health system resources can be deployed in an efficient manner to provide coordinated and accountable care for patients.

Acknowledgments

The authors thank collaborating pharmacists, social workers, nurse practitioners, and medical doctors at Turner Geriatric Clinic for providing care for patients during Transitional Care Program appointments. They also thank pharmacists Stuart Rockafellow, PharmD, and Scott Vouri, PharmD, for their efforts in study planning, data analysis, and/or critical revisions. Dr Stranges and Mr Marshall had full access to study data and take responsibility for the integrity of the data and the accuracy of the data analysis.

Author Affiliations: University of Michigan Health System (PMS, PCW, KEH, DKG, TR), Ann Arbor, MI; University of Michigan College of Pharmacy (PMS, VDM, PCW, TR), Ann Arbor, MI; Ann Arbor VA Healthcare System (KEH), Ann Arbor, MI; St. Louis College of Pharmacy (PMS), St. Louis, MO.

Source of Funding: None.

Author Disclosures: Dr Hall reports that she receives honoraria from and has attended meetings on behalf of Blue Cross Blue Shield of Michigan for the Formulary Committee. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (PMS, PCW, DKG, TR); acquisition of data (PMS, PCW, VDM, TR); analysis and interpretation of data (PMS, PCW, VDM, TR); drafting of the manuscript (PMS, KEH); critical revision of the manuscript for important intellectual content (PMS, PCW, KEH, DKG, VDM, TR); statistical analysis (PMS, VDM); administrative, technical, or logistic support (DKG, VDM, TR); and supervision (KEH, TR).

Address correspondence to: Tami Remington, PharmD, University of Michigan College of Pharmacy and Health System, 4201 Plymouth Rd, SPC 5797, Ann Arbor, MI 48109. E-mail: remingtn@med.umich.edu.
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