Implementation of a Cardiac Transitions of Care Pilot Program: A Prospective Study of Inpatient and Outpatient Clinical Pharmacy Services for Patients With Heart Failure Exacerbation or Acute Myocardial Infarction

J Pharm Pract. 2019 Feb;32(1):68-76. doi: 10.1177/0897190017743129. Epub 2017 Nov 28.


Background:: Pharmacists may assist with reducing 30-day readmission rates for patients with heart failure (HF) exacerbation or acute myocardial infarction (AMI) by promoting medication adherence.

Objective:: To determine the change in 30-day readmission rates for patients with HF exacerbation or AMI after implementation of a "high-touch" standard of care.

Methods:: Patients admitted with HF exacerbation, non-ST-segment elevation AMI, or ST-segment elevation AMI from August 1, 2013, to June 30, 2015, were included in this prospective study. Patients were educated while in the inpatient setting and followed up in the outpatient setting through telephone contact and scheduling a medication therapy management (MTM) appointment with a pharmacist. Data were collected by pharmacy personnel involved in the implementation of the intervention.

Results:: Within the HF and AMI arms, 100 and 93 patients, respectively, were included in the study. The 30-day readmission rates were 24% and 17.2% for HF and AMI, respectively, which were not statistically significant when compared to historical institutional readmission rates prior to study initiation (18.2% for HF, P = .238; 11.4% for AMI, P = .252).

Conclusion:: A "high-touch" pharmacist-driven transitions of care program may affect 30-day readmission rates for patients with HF exacerbation or AMI; potential processes for initiating transitions of care programs are provided.

Keywords: cardiology; medication therapy management; patient education; readmission; transitions of care.

Publication types

  • Comparative Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Ambulatory Care / organization & administration
  • Female
  • Heart Failure / drug therapy*
  • Humans
  • Male
  • Medication Adherence
  • Medication Therapy Management / organization & administration
  • Middle Aged
  • Non-ST Elevated Myocardial Infarction / drug therapy*
  • Patient Education as Topic / methods
  • Patient Readmission / statistics & numerical data
  • Patient Transfer / organization & administration
  • Pharmacists / organization & administration*
  • Pharmacy Service, Hospital / organization & administration*
  • Pilot Projects
  • Professional Role
  • Prospective Studies
  • ST Elevation Myocardial Infarction / drug therapy*