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The American Journal of Managed Care July 2019
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Evaluation of Interdisciplinary Geriatric Transitions of Care on Readmission Rates
Nada M. Farhat, PharmD; Sarah E. Vordenberg, PharmD, MPH; Vincent D. Marshall, MS; Theodore T. Suh, MD, PhD, MHS; and Tami L. Remington, PharmD

Evaluation of Interdisciplinary Geriatric Transitions of Care on Readmission Rates

Nada M. Farhat, PharmD; Sarah E. Vordenberg, PharmD, MPH; Vincent D. Marshall, MS; Theodore T. Suh, MD, PhD, MHS; and Tami L. Remington, PharmD
An interdisciplinary transitions of care service composed of nurse navigators, pharmacists, and medical providers reduced 30-day hospital readmissions among patients who received all components of the intervention.
Patients completing all components of the intervention (PP and AT) were found to be readmitted less often than those in our control population at 30 days. In the ITT population, there was no difference in readmission, demonstrating the importance of each component of the interdisciplinary TOC intervention working collectively to improve patient outcomes. Despite process improvement efforts to increase completion of interventions, more than half of the patients in the ITT population did not receive all 3 components (nurse, pharmacist, and physician appointment), which may have influenced patient readmission outcomes. However, many patients completed at least 1 component of the intervention (ie, were seen by a provider or had contact with a nurse navigator or pharmacist). This may be due to a variety of factors, including that patients at highest risk of rehospitalization may also be at a higher risk of not completing outpatient TOC services. Examples include patients who may be more acutely ill or those with complicated psychosocial factors that may prevent them from completing TOC services, potentially influencing their rates of rehospitalization. Further data analysis regarding reasons for noncompletion of visits is in progress.

Of note, patients were scheduled for these visits as a combined result of their day of hospital discharge, schedule of providers (including physicians, nurses, and pharmacists), and patient availability. We identified several opportunities for further process improvement, including earlier nurse navigator contact after discharge and improvements in consistent scheduling and completion of TOC appointments.


Compared with our previous study, readmission rates were considerably lower than expected in both the intervention and control groups.9 Preliminary efforts were made at the health system level to more actively involve nurse navigators in TOC services; however, we are unaware of large-scale efforts during our study that could have confounded our results.

The availability and accuracy of information in the EHR may be a limitation. Although this was a single-center study, limiting our external validity, the results of this study may be applicable to other institutions with similar practice models. Potential confounding variables that were not studied included variables such as social support concerns, health literacy, and socioeconomic status; we did not control for these, but all may potentially contribute to higher readmission rates.11 Further studies are needed to identify how these factors may affect hospital readmission rates. Additionally, our study was not powered to evaluate differences in readmission rates based on specific patient age or on causes of the original hospital admission and readmission, but these factors may be important for future studies to consider.

Provider Roles

The goal of this study was to capture the effectiveness of the intervention provided by the TOC team; thus, the role of each provider was not assessed in detail. However, our results support the importance of early intervention by nurse navigators because patients who were not readmitted were contacted by a nurse navigator sooner than those who were readmitted. One meta-analysis found that care coordination by a registered nurse within 1 week of discharge was essential to reducing 30-day hospital readmission rates.12 Additional studies are needed to determine the role of nursing in our program, as the previous iteration of the model did not include nurse navigators as a core component of the program. However, the results of our study and current literature support the role of a nurse as a care coordinator for patients recently discharged from the hospital setting.

Regarding the role of pharmacists in our study, a recent meta-analysis demonstrated that pharmacy-supported TOC programs were associated with an improvement in 30-day hospital readmission rates.13 Coleman et al found that 14% of older adults had 1 or more medication discrepancy at discharge, and this was correlated with higher 30-day readmission rates (14.3% vs 6.1%; P = .04).14 A more recent study of an insurer-initiated TOC program found that pharmacist-led medication reconciliation was responsible for a 50% reduction in 30-day hospital readmissions.15 Although it is difficult to extrapolate pharmacist-specific attribution to the reduced readmission rates in our study given that this is an interdisciplinary team approach, the role of medication management has been demonstrated to be a key factor in reducing hospital readmissions.16 In addition, pharmacists in our TOC intervention group not only completed medication reconciliation but also assessed medication tolerability, adherence, and cost. These concerns were then shared with the medical provider to facilitate simplification of regimens or changes to alternative therapies due to AEs, nonadherence, or cost concerns.


An interdisciplinary team based in a PCMH did not improve readmission rates for all patients eligible for the intervention. However, patients who completed all components of the intervention experienced significantly lower risk of readmission at 30 days post index hospitalization. Further exploration of factors contributing to patients not completing all components will guide process improvements aimed at improving readmission rates.

Author Affiliations: University of Michigan College of Pharmacy (NMF, SEV, VDM, TLR), Ann Arbor, MI; Henry Ford Hospital (NMF), Detroit, MI; Michigan Medicine (SEV, TTS, TLR), Ann Arbor, MI; Geriatric Research Education and Clinical Center, Ann Arbor VA Hospital (TTS), Ann Arbor, MI.

Source of Funding: The American College of Clinical Pharmacy Ambulatory Care Practice Based Research Network Seed Grant funded a portion of this study. The remaining funding was provided through institutional support from our respective health institutions.

Author Disclosures: The 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 (NMF, SEV, TLR); acquisition of data (NMF, VDM, TLR); analysis and interpretation of data (NMF, SEV, VDM, TTS, TLR); drafting of the manuscript (NMF, VDM, TTS, TLR); critical revision of the manuscript for important intellectual content (NMF, SEV, VDM, TTS); statistical analysis (VDM); obtaining funding (SEV); and supervision (SEV, TLR).

Address Correspondence to: Nada M. Farhat, PharmD, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202. Email:

1. Hospital Readmissions Reduction Program (HRRP). CMS website. Updated January 16, 2019. Accessed June 14, 2019.

2. Arbaje AI, Kansagara DL, Salanitro AH, et al. Regardless of age: incorporating principles from geriatric medicine to improve care transitions for patients with complex needs. J Gen Intern Med. 2014;29(6):932-939. doi: 10.1007/s11606-013-2729-1.

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8. Engel PA, Spencer J, Paul T, Boardman JB. The Geriatrics in Primary Care demonstration: integrating comprehensive geriatric care into the medical home: preliminary data. J Am Geriatr Soc. 2016;64(4):875-879. doi: 10.1111/jgs.14026.

9. Stranges PM, Marshall VD, Walker PC, Hall KE, Griffith DK, Remington T. An interdisciplinary intervention for reducing readmission among older adults in a patient-centered medical home. Am J Manag Care. 2015;21(2):106-113.

10. Desai MM, Bogardus ST Jr, Williams CS, Vitagliano G, Inouye SK. Development and validation of a risk-adjustment index for older patients: the High-Risk Diagnoses for the Elderly Scale. J Am Geriatr Soc. 2002;50(3):474-481. doi: 10.1046/j.1532-5415.2002.50113.x.

11. Wolf MS, Lambert BL, Hickner J. Promoting health literacy to prevent hospital readmissions: necessary but not sufficient. J Gen Intern Med. 2016;31(5):455-457. doi: 10.1007/s11606-016-3658-6.

12. Nelson JM, Pulley AL. Transitional care can reduce hospital readmissions [continuing education]. Am Nurse Today. 2015;10(4):8. Accessed June 14, 2019.

13. Rodrigues CR, Harrington AR, Murdock N, et al. Effect of pharmacy-supported transition-of care interventions on 30-day readmissions: a systematic review and meta-analysis. Ann Pharmacother. 2017;51(10):866-889. doi: 10.1177/1060028017712725.

14. Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165(16):1842-1847. doi: 10.1001/archinte.165.16.1842.

15. Polinksi JM, Moore JM, Kyrychenko P, et al. An insurer’s care transition program emphasizes medication reconciliation, reduces readmissions and costs. Health Aff (Millwood). 2016;35(7):1222-1229. doi: 10.1377/hlthaff.2015.0648.

16. Ekerstad N, Bylin K, Karlson BW. Early rehospitalizations of frail elderly patients—the role of medications: a clinical, prospective, observational trial. Drug Healthc Patient Saf. 2017;9:77-88. doi: 10.2147/DHPS.S139237.
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