{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,28]],"date-time":"2026-04-28T23:52:52Z","timestamp":1777420372529,"version":"3.51.4"},"reference-count":25,"publisher":"SAGE Publications","issue":"8","license":[{"start":{"date-parts":[[2025,1,25]],"date-time":"2025-01-25T00:00:00Z","timestamp":1737763200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"funder":[{"DOI":"10.13039\/100008168","name":"hennepin health foundation","doi-asserted-by":"publisher","award":["Hennepin Healthcare Reinvestment and Innovation Gr"],"award-info":[{"award-number":["Hennepin Healthcare Reinvestment and Innovation Gr"]}],"id":[{"id":"10.13039\/100008168","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Ann Pharmacother"],"published-print":{"date-parts":[[2025,8]]},"abstract":"<jats:sec>\n                    <jats:title>Background:<\/jats:title>\n                    <jats:p>Limited data exist describing the influence of pharmacist-led transition of care (TOC) services in safety-net hospital settings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective:<\/jats:title>\n                    <jats:p>This analysis assessed the impact of pharmacist-led TOC services on hospital readmissions in a high-risk managed Medicaid population impacted by housing instability, substance use disorder (SUD), and mental health issues.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>A retrospective evaluation of patients who received safety-net hospital-based TOC pharmacy services between January 1, 2022, and December 31, 2022, was conducted. Patients 18 years and older, insured by a select managed Medicaid plan, and admitted to an inpatient medicine service were included. Patients were excluded if they were admitted from or discharged to a facility or hospice, discharged before medically ready, or died within 30 days of discharge. Interventions included an initial visit, discharge medication delivery and education, and a post-discharge follow-up phone call within 24 to 72 hours. Patients were provided with a number to call for medication-related questions post-discharge. The primary outcome was 30-day hospital readmissions. Secondary outcomes included time to and reason for readmission and a description of TOC services.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>There were 292 patients engaged in pharmacist-led TOC services. Nearly 1 in 6 patients were experiencing homelessness and almost 40% were struggling with SUD during the index admission. The median readmission performance in the target population 6 months prior to TOC service implementation was 20.2% and fell to 12.3% post-intervention. Substance use disorder was the leading contributor to re-hospitalization, accounting for 58% of readmissions. Six (16.7%) readmissions were medication-related; 5 of 6 were complicated by SUD. There were no preventable medication-related readmissions. There are limitations to this study; not all patients received all TOC program components. Prospective, randomized-controlled studies are needed to show cause and effect.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion and Relevance:<\/jats:title>\n                    <jats:p>This evaluation suggests pharmacist-led TOC discharge services may lead to hospital readmission reduction in a socially complex managed Medicaid population in a safety-net hospital setting.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/10600280241310862","type":"journal-article","created":{"date-parts":[[2025,1,27]],"date-time":"2025-01-27T21:16:59Z","timestamp":1738012619000},"page":"736-742","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":1,"title":["Pharmacist-Directed Transition of Care Services Decrease Readmissions at a Safety-Net Hospital"],"prefix":"10.1177","volume":"59","author":[{"given":"Shannon","family":"Carboni","sequence":"first","affiliation":[{"name":"Hennepin Healthcare, Minneapolis, MN, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Monika","family":"Tawfik","sequence":"additional","affiliation":[{"name":"Hennepin Healthcare, Minneapolis, MN, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Brooke","family":"Menon","sequence":"additional","affiliation":[{"name":"Hennepin Healthcare, Minneapolis, MN, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0480-5829","authenticated-orcid":false,"given":"Heather","family":"Rhodes","sequence":"additional","affiliation":[{"name":"Hennepin Healthcare, Minneapolis, MN, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ann","family":"Brigino","sequence":"additional","affiliation":[{"name":"Hennepin Healthcare, Minneapolis, MN, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"179","published-online":{"date-parts":[[2025,1,25]]},"reference":[{"key":"e_1_3_2_2_2","unstructured":"Agency for Healthcare Research and Quality. Transitions of care. Content last reviewed June 2018. Accessed October 10 2024. https:\/\/www.ahrq.gov\/research\/findings\/nhqrdr\/chartbooks\/carecoordination\/measure1.html"},{"key":"e_1_3_2_3_2","doi-asserted-by":"publisher","DOI":"10.1097\/01.NAJ.0000336420.34946.3a"},{"key":"e_1_3_2_4_2","unstructured":"Vernon JA Trujillo A Rosenbaum S DeBuono B. Low Health Literacy: Implications for National Health Policy. University of Connecticut; 2007. Accessed October 10 2024. https:\/\/hsrc.himmelfarb.gwu.edu\/cgi\/viewcontent.cgi?article=1173&context=sphhs_policy_facpubs"},{"key":"e_1_3_2_5_2","doi-asserted-by":"publisher","DOI":"10.5888\/pcd21.240138"},{"key":"e_1_3_2_6_2","volume-title":"Healthcare Cost and Utilization Project (HCUP) Statistical Briefs","author":"Hines AL","year":"2006","unstructured":"Hines AL, Barrett ML, Jiang HJ, Steiner CA. Conditions with the largest number of adult hospital readmissions by Payer, 2011. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Statistical Brief #172.2014 Apr. Agency for Healthcare Research and Quality (US); 2006."},{"key":"e_1_3_2_7_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMsa0803563"},{"key":"e_1_3_2_8_2","doi-asserted-by":"publisher","DOI":"10.1097\/CCM.0000000000000859"},{"key":"e_1_3_2_9_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jamda.2015.11.005"},{"key":"e_1_3_2_10_2","volume-title":"Final Evaluation Report: Evaluation of the Community-based Care Transitions Program","author":"Econometrica Inc","year":"2017","unstructured":"Econometrica Inc. Final Evaluation Report: Evaluation of the Community-based Care Transitions Program. Econometrica, Inc; 2017. Evaluation of the Community-Based Care Transitions Program"},{"key":"e_1_3_2_11_2","unstructured":"Agency of Healthcare Research and Quality. Conditions with the largest number of adult hospital readmissions by Payer 2011. https:\/\/hcup-us.ahrq.gov\/reports\/statbriefs\/sb172-Conditions-Readmissions-Payer.pdf"},{"key":"e_1_3_2_12_2","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0229940"},{"key":"e_1_3_2_13_2","doi-asserted-by":"publisher","DOI":"10.1111\/jgs.15244"},{"key":"e_1_3_2_14_2","volume-title":"Medication Safety in Transitions of Care: Technical Report","author":"World Health Organization","year":"2019","unstructured":"World Health Organization. Medication Safety in Transitions of Care: Technical Report. (WHO\/UCH\/SDS\/2019.9). Licence: CC BY-NC-SA 3.0 IGO. World Health Organization; 2019."},{"key":"e_1_3_2_15_2","volume-title":"Medication Without Harm: Policy Brief","author":"World Health Organization","year":"2023","unstructured":"World Health Organization. Medication Without Harm: Policy Brief. Licence: CC BY-NC-SA 3.0 IGO. 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