Running Head: UTILIZATION OF TRANSITIONAL CARE TEAM 1 Utilization of a Transitional Care Team for Medication Reconciliation in Geriatric Primary Care Tanya Brooks, Kristen Campbell, Chelsea Pettit, and Sam Singh Michigan State University UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 2 Contents Abstract ......................................................................................................................................3 Background and Significance ......................................................................................................5 Clinical Problem Statement .........................................................................................................7 Description of Clinic ...................................................................................................................7 Goals and Outcome Measures .....................................................................................................9 Evidence-Based Practice Model ................................................................................................ 10 Literature Review ...................................................................................................................... 11 Methods .................................................................................................................................... 22 Results ...................................................................................................................................... 27 Discussion................................................................................................................................. 28 Conclusion ................................................................................................................................ 36 Appendices ............................................................................................................................... 46 Appendix A ........................................................................................................................... 46 Appendix B ........................................................................................................................... 47 Appendix C ........................................................................................................................... 48 Appendix D ........................................................................................................................... 49 Appendix E ........................................................................................................................... 64 Appendix F ............................................................................................................................ 65 Appendix G .......................................................................................................................... 66 Appendix H ........................................................................................................................... 68 Appendix I............................................................................................................................. 69 UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 3 Abstract Background and Significance: According to the Institute of Medicine (IOM), medication-related errors lead to mortality and adverse effects such as allergic reactions, avoidable side effects, drug interactions, and unnecessary cost (IOM, 2000). Even with the predominant use of computerized provider order entry (CPOE) and clinical decision support systems (CDSS), medication discrepancies are still problematic today. There is substantial evidence available to demonstrate the benefits of using a transition of care (TOC) team for timely, appropriate medication reconciliation (MR) utilizing multiple intervention modalities. Purpose: This quality improvement (QI) project attempted to determine if the implementation of a TOC team utilizing a telephone-based MR system in a geriatric primary care setting improved identification of medication discrepancies and improved seven-day follow-up (FU) appointments following an inpatient admission. Methods: The TOC team at the geriatric primary care clinic was educated about the improved MR intervention tool and data collection process via a PowerPoint presentation. The data was collected via an Excel spreadsheet and analyzed for improvement upon identified medication errors and follow-through with timely FU appointments. The plan-do-study-act (PDSA) cycle was utilized for implementation. Results: A QI project was implemented in a geriatric primary care setting including 74 patients, 18 of which received the intervention. The implementation was carried out over a total of 12 weeks. Error identification increased from 0.71 errors per patient in the control group to 1.22 in the intervention group. Of the patients contacted via MR phone calls, 88.8% scheduled FU UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 4 appointments; only 38.8% were within the goal time frame of seven days. The average time to FU during the implementation period was 9.1 days. Conclusion: The TOC team utilizing a telephonic MR improved identification of medication errors and overall FU rates. However, the TOC team did not positively impact the seven-day FU during MR from an inpatient hospitalization visit back to the outpatient setting. Results also indicated an improvement in the time spent per phone call. Keywords: care transition, transition of care team, medication reconciliation, seven-day follow- up, outpatient/ambulatory primary care UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 5 Background and Significance Two decades have passed since the IOM released To Err is Human (2000) which focused on the chasms in healthcare regarding medication safety; however, the effort to improve upon safe medication administration continues today. When the IOM report was released, 98,000 Americans were dying each year due to medical errors while hospitalized; medication errors accounted for 1 in every 131 deaths occurring in the outpatient setting (IOM, 2000). Up to 56% of discrepancies occurred during the ordering phase due to illegible handwriting or inappropriate use of abbreviations (Bates et al., 1995). While not all medication-related errors lead to patient mortality, adverse drug effects (ADE) encompass various conditions detrimental to Americans’ healthcare: including allergic reactions, avoidable side effects (SE), drug interactions, and unnecessary costs with estimates as high as $37 billion annually (IOM, 2000). At the time of the IOM publication, many healthcare providers (HCP) were still utilizing written ordering systems leading to a medication ordering error rate of 5.3%. Research demonstrated that computerized ordering and proper review would prevent over 80% of missing dose errors and ADE (IOM, 2000). A classic study focused on ADE found a rate of 6.5 per 100 inpatient admissions with an additional 5.5 potential ADE identified (Bates et al., 1995). Of the ADE recognized, 1% were determined to be fatal and unpreventable, 12% were life-threatening, and 30% were labeled as serious risk (Bates et al., 1995). Fast forward to two decades later, medication errors continue to be a costly healthcare problem. To further emphasize the importance of safe medication prescribing, The Joint Commission (2021) recently focused their efforts on safe MR as one of the 2021 National Patient Safety Goals. UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 6 Today, CPOE and CDSSs have helped to greatly reduce the incidence of medication errors throughout the healthcare system (Prgomet, Niazkhani, Georgiou, & Westbrook, 2016). CPOE refers to programs used in healthcare systems which give the provider the ability to electronically place orders which are then sent directly to the order recipient (Agency for Healthcare Research and Quality [AHRQ], 2019a). CDSSs are technology-based programs that evaluate the orders HCP enter into an electronic health record (EHR), compare the data with the patient chart, and provide feedback based on the evidence-based guidelines (Centers for Disease Control and Prevention [CDC], 2020). This feedback can be in the form of screening reminders or prompts that aid the HCP in making appropriate clinical decisions based on treatment protocols (CDC, 2020). The development of these systems focused on improving medication safety by including a multi-step check process where discrepancies could be addressed by a variety of members of the interdisciplinary team (IDT) (AHRQ, 2019a). Since CPOE systems do not use written orders, transcribing errors are kept to a minimum (AHRQ, 2019a). Both CPOE and CDSSs can be used for quick and easy ordering of testing, medical procedures, and additional consultations (AHRQ, 2019a). Even with the predominant use of CPOE and CDSSs, medication discrepancies are still problematic today. Approximately 38% of patient charts reviewed had some form of discrepancy, contributing the majority of errors to accidental additions (Caleres, Modig, Midlov, Chalmers, & Bondesson, 2020). Similarly, a study conducted by Breuker et al. (2017) determined that nearly 30% of patients admitted to the hospital had at least one medication error either during admission or discharge; however, the study concluded that 59.3% of errors were related to omissions. Up to 50% of medication errors were determined to occur during TOC with UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 7 30% of errors containing the potential to cause harm (Elbeddini et al., 2021). Additionally, Weir et al. (2019) recognized that several discrepancies could be directly related to medications that were never filled or were filled at an incorrect dosage. The risk of patients failing to follow through with prescribed medication dosages positively correlated with higher out-of-pocket costs, medications not dispensed at inpatient discharge, and discharges to long-term care (LTC) facilities (Weir et al., 2019). Clinical Problem Statement Within the Rosa Parks Geriatric Center (RPGC) in Detroit, Michigan, currently there is not an effective TOC model in place to aid with MR for patients transitioning from an inpatient to outpatient setting. Will the implementation of a TOC team utilizing a telephone-based MR system within the RPGC improve identification of medication discrepancies and seven-day FU appointments following an inpatient admission? Description of Clinic RPGC is a senior-centered, hospital-associated healthcare facility that utilizes interdisciplinary care throughout the clinic to provide specialty care to older adults (OA) in the community. Geriatricians, nurse practitioners (NP), social workers (SW), registered nurses (RN), medical fellows, pharmacists, and pharmacy students work collaboratively to ensure high-quality care among their patient population, consisting of a majority of African American patients over the age of 65 who reside within the city limits. The clinic sees approximately 2,500 patients divided between four geriatricians and one NP. The average age of patients is 78 years old, majority female, and 90% enrolled in Medicare. More than two chronic illnesses are seen in 85% of the patient population with an average of 8-10 prescription medications per patient. Organizational Assessment UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 8 Prior to the coronavirus (COVID-19) pandemic, the clinic had adopted a TOC model to improve MR and patient FU appointments in the time following discharge from hospital admission, this model employed a phone call-based program that began with pharmacy staff reaching out to patients (Liu et al., 2019). The goal was to connect with patients within two days of discharge to review medications, provide education, update medication lists, and assist patients with maintaining their supply (Liu et al., 2019). While logical, the model adopted by the clinic was not without barriers and limitations that included: (1) difficulty reaching patients over the phone due to disconnected lines and wrong numbers in 40% of cases, (2) staff and time restraints that limited the number of calls made (Liu et al., 2019). Once pandemic was declared, changes occurred in the clinic, staff focus turned to prevention of COVID-19, and efforts toward improving current TOC processes were abandoned. Setting facilitators and barriers. Modifying a practice procedure in an IDT organization requires a strategy that identifies and builds on strengths while minimizing weaknesses and threats of the proposed change. A strengths, weaknesses, opportunities, and threats (SWOT) table is a commonly used audit and analysis tool that helps to identify barriers and facilitators when implementing a new project. Using a SWOT table identifies and organizes these issues to guide the development of a MR QI proposal (Management Study Guide, 2021). After shared group analysis of articles selected from the literature review, and discussion with the stakeholder providing insight into the organization's method of operation, organizational goals and culture, specific barriers and facilitators to the project were identified. These are summarized in Appendix A, Table 1. Gap analysis. UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 9 The RPGC does not have a consistent TOC process to appropriately address MR and FU procedures. The clinic conducted their own research evaluation based on the implementation of a post-discharge reconciliation team and concluded there were several clinic-specific barriers to an effective TOC. These barriers included:  lack of communication with patients,  limited transportation availability,  staff time constraints (Liu et al., 2019). A preferred approach during TOC addresses all barriers to a smooth transition from inpatient facilities to the RPGC to reduce medication errors and increase timely patient FU. Although there was a procedural TOC practice in place prior to the beginning of this project, efforts to improve upon it were halted due to COVID-19. A thorough evaluation of additional cause and effect aspects to identify care gaps leading to beneficial and properly functioning TOC team for the RPGC can be found in Appendix B, Figure 1. Goals and Outcome Measures The goal of this project was to create and implement an improved and concise medication management data process within the clinic. This process would ensure medications were addressed when transitioning back into the outpatient setting to prevent possible transcription errors, duplications, omissions, and ensure the appropriate FU appointments were being scheduled in a timely manner. This was accomplished by reviewing the limitations of the current system in place, discussing preferences with the facility staff, and designing innovative solutions to better the MR process. The primary outcome measure for this project was the MR completion rate. MR completion was defined as the successful fulfillment of all key categories for review. These UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 10 categories focused on medication additions, omissions, dosage adjustments, drug interactions, and medication obtainment. Scheduling of FU appointments to the RPGC was measured as a secondary outcome. The appointments had to occur within seven days of discharge from an inpatient facility to meet the project goal. Evidence-Based Practice Model Lewin’s Change Model A variety of models can be used to help formulate the basis of any QI project. One common model was created by Lewin in 1947 and is considered to be a highly influential theory (Wojciechowski, Pearsall, Murphy, & French, 2016). Lewin’s Change Theory (LCT) is based on a three-step model known as the unfreezing-change-refreeze model (Wojciechowski et al., 2016). The unfreezing stage focuses on past procedures, which were determined to be less productive methods, and helps to visualize the possible improvement opportunities. Once areas of opportunity are identified, the change stage begins. The change process involves altering a combination of patterns of thoughts, behaviors, or emotions leading to prolific beneficial outcomes. A crucial step at this stage is the proper education and understanding of how change will be beneficial in the end (Mind Tools, n.d.). Finally, the refreezing stage solidifies the new change in procedure or process as a new standard of practice (Wojciechowski et al., 2016). Theoretically, this final stage prevents the reversion back to old habits. By implementing LCT into practice, one can expect to establish sustainable methods of process improvement. This QI project sought to improve upon an outdated and underutilized TOC process. LCT was implemented to guide the identification of counterproductive processes within the practice, provide education as to why it was imperative to necessitate change, reformulate procedures, and ensure the successful execution of a new and improved TOC process. UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 11 PDSA Tool The PDSA process is an important tool used for QI or to test change on a small scale (Institute for Healthcare Improvement [IHI], 2021a). The PDSA tool helps determine if a change or improvement has occurred (IHI, 2021b). The planning process is where the plan is established, including the proposed question or change, predicted outcomes, the who, what, when, and where of the plan, and determines what data will need to be collected to include in the plan (IHI, 2021c). Step two, or do, requires the implementation of a change on a small scale in order to identify issues with the executed plan and begin to analyze effective and ineffective aspects of the project plan. This then moves into the study phase of the process (IHI, 2021c). Analysts must compare and disseminate data retrieved from the enacted project to determine modifications that should be made to current methods to improve upon outcomes to reach predicted project goals (IHI, 2021c). After examining the beneficial segments of a plan, step four, or the act phase, is initiated. Changes are made to disadvantageous project aspects and a plan is prepared for beginning an implementation of a new round of testing (IHI, 2021c). Since the PDSA tool involves continually analyzing and adjusting the enacted plan to meet project goals, it was chosen to help guide measures when beginning this QI project (see Appendix C). Utilizing this tool incentivized members involved to be open to change by aiding in the identification of areas of opportunity. The plan step was carried out by completing a thorough review of current, evidence-based literature, as well as meeting with stakeholder leaders and creating examination tools, such as the SWOT table and Fishbone Analysis. After a proper evaluation of current trends and the examination of clinical barriers, the QI team, with the cooperation of pharmacy members, instituted a new method of TOC FU that improved upon previous models used in the RPGC. Literature Review UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 12 Search Methods A systematic literature search was conducted May through July 2021 to examine current literature standards and data regarding MR benefits transitioning from the inpatient setting back to outpatient care. The search focused on evidence-based publications derived from database searches using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Google Scholar, and PubMed. Key search terms included, but were not limited to, the following: medication reconciliation, medication errors, telephone/telephonic intervention, transitions of care, transitions of care team, outpatient/ambulatory, primary care, discharge, and care transition. Selection Criteria Due to the abundance of information, the search was limited to publications within five years (2016-2021). Additional eligibility for inclusion were peer-reviewed articles written in English with research based within the United States (US), Canada, Australia, or the United Kingdom, as well as their relevance to the beneficial patient outcomes related to MR programs. Studies were initially screened using the title and abstract of the article to determine overall relevance to the project. Additionally, two landmark studies were incorporated to provide key background information (Bates et al.,1995; IOM, 2000). Exclusion criteria included sample sizes under 100, research published prior to 2016, articles written in a language other than English, and inconclusive data. Each selected study was analyzed for sample size, design, aspects of intervention, and overall outcome with a focus on medication discrepancy improvement and benefits of a TOC team. Articles reviewed can be found in Appendix C, Table 2. Throughout hospital admissions and stays within other inpatient facilities, OA are susceptible to medical errors which result from MR miscommunications between their inpatient and outpatient HCP. Within the US, an average of 100,000 hospitalizations per year in patients UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 13 65 and older can be directly related to medication ADEs (Pellegrin et al., 2016). Due to this increase in acute care needs, it is imperative that communication between facilities and systems remains as cohesive and clear as possible. Creating an interdisciplinary TOC team is an effective way to ensure patients inpatient to outpatient medications have been reconciled properly to promote patient safety and decrease the risk of adverse patient outcomes (Liu et al., 2019; Neu et al., 2020; Xuan et al., 2021). Transitions of Care The TOC from hospital to primary care can be challenging as patients and caregivers start to bear the responsibility of care coordination. During TOC, patients are bombarded with new information, medications, and FU responsibilities including setting up appointments with HCP (Bajorek & McElroy, 2020). Transitions between HCP have been identified as the time when the patient is most vulnerable and timely FU with the HCP is required to optimize the TOC. Past research on TOC has demonstrated a large gap with patient continuity of care. Landmark studies continue to confirm that OA are at an increased risk for adverse events due to medication errors (Corbett, Setter, Daratha, Neumiller, & Wood, 2010). These patients are particularly at risk due to the complexities of medication regimens, polypharmacy, frequent changes of medication treatment during hospitalization, multiple HCP prescribing medication without collaboration, and chronic comorbidities (Corbett et al., 2010). The gaps in continuity of care during transitions have prompted the development and implementation of TOC protocols. The timeliness of proper FU requires seamless integration of services to reduce the risk of adverse events, including hospital readmissions (Lowthian, 2017). Programs focusing on providing support to patients, improving skills of HCP, enhancing health information technologies, implementing system-level interventions, developing performance measures, UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 14 influencing health policies, and improving public reporting mechanisms are part of TOC strategies (Khalil et al., 2017; Redmond et al., 2018). OA have more complex health concerns and are more vulnerable during TOC (Naylor & Keating, 2008). Due to complexities of multiple health challenges, including cognitive deficits often seen in dementia, persuading patients and caregivers to participate in TOC is difficult (Prusaczyk et al., 2020). This deficiency in OA patient participation is due in part by the reluctance of patients to initiate active participation in the process (Rustad, Furnes, Cronfalk, & Dysvik, 2016). When coordinating TOC with OA greater than 65 years of age, HCP are encouraged to formally invite patients to participate in the transition of their care (Rustad et al., 2016). Studies have shown that OA accustomed to the patriarchal nature of the healthcare system in the past are less likely to take an active role in their health without a specific request to participate (Rustad et al., 2016). Strategies to encourage engagement and empower OA include communication and education focused to inform and educate older patients while keeping in mind their level of healthcare literacy (Rustad et al., 2016). Medication errors and discrepancies during TOC is a significant problem that requires person-centered care. It has been identified that MR is a high priority for decreasing medication errors occurring during the post-discharge TOC (Corbett et al., 2010). The World Health Organization (2016) describes the key components of MR as the  identification of current medications,  creation of a medication list as prescribed,  comparison of current medications to make clinical decisions,  education of patients and caregivers about the medications on the list, and  providing access to this information to other HCP. UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 15 Involving patients and their caregivers, maintaining up-to-date medications, and the embracement of accountability by HCP at all levels of care can reduce medication error rates (Wheeler et al., 2018). Benefits of Interdisciplinary Medication Reconciliation Teams There is a substantial amount of evidence available to demonstrate the advantages and beneficial outcomes of using a TOC team for timely, appropriate MR utilizing multiple intervention modalities. Most TOC teams adopt interdisciplinary models that include pharmacy staff members (Liu et al., 2019; Neu et al., 2020; Xuan et al., 2021). These members have played significant roles in identifying and limiting the number of discrepancies found in patient charts (Liu et al., 2019; Neu et al., 2020). The utilization of such teams illustrates the positive impact collaborating healthcare personnel can have on patient outcomes, which include reducing 30-day adverse medication events and hospital readmissions (Liu et al., 2019; Neu et al., 2020; Xuan et al., 2021). Effects on healthcare costs and patient outcomes. Numerous studies have found that over 80% of charts audited by a TOC team have at least one medication discrepancy, which included dosage errors, duration issues, and documentation inconsistencies (Albano et al., 2018; Surbhi et al., 2016). These studies demonstrate the cost-effectiveness and other benefits of post-discharge FU by HCP (Liu et al., 2019; Neu et al., 2021; Tomlinson et al., 2020). The potential ADEs identified using MR programs avoided over an estimated $370,000 in physician visits, hospitalizations, emergency department (ED) utilization, and prescription costs with an average of $293.30 saved per medication claim (Surbhi et al., 2016). Not only do medication discrepancies lead to increased healthcare costs, they also affect patient well-being. By preventing drug therapy related UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 16 inconsistencies, quality of care improved an approximated 43% due to an increase in medication adherence and the recognition of gaps in care through medication counseling and review (Surbhi et al., 2016). Medication errors. Throughout the literature reviewed, medication discrepancies were abundant in charts audited by a TOC team (Albano et al., 2018; Liu et al., 2019; Surbhi et al., 2016). Liu et al. (2019) identified medication-related inconsistencies in 89.8% of charts reviewed with an average of 3.6 errors per telephone call. Another study found 1416 discrepancies throughout 438 charts reviewed over the course of 18 months (Albano et al., 2018). Medication additions and deletions accounted for the majority of discrepancies (77.5%) with 22.5% attributed to incorrect frequency or dosage strengths (Albano et al., 2018). Medication supply and prescription access are also key problematic areas for TOC teams that affect patient continuity of care (Albano et al., 2018; Liu et al., 2019). Albano et al. (2018) found that 33.4% of participants in their study did not receive their prescribed medications upon discharge from an inpatient facility. However, some studies found little statistically significant evidence that TOC team usage was associated with better medication discrepancy outcomes (Khalil et al., 2017; Redmond et al., 2018). The use of a timely TOC intervention has the potential to aid in preventing diverse forms of medication errors from occurring until the patient presents for an office visit. Hospital readmissions. An additional area of influence on patient outcomes is the rate of 30-day hospital readmissions. The use of TOC teams to reconcile hospital medications upon discharge positively impacts readmission rates (Liu et al., 2019; Tomlinson et al., 2020). A systematic review of over 17,000 cases conducted by Tomlinson et al. (2020) concluded that thorough MR leads to a successful TOC between healthcare settings and also reduces the prevalence of hospital UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 17 readmissions related to adverse events. Various studies have also demonstrated significant statistical outcomes on readmission rates with the application of scheduled medication review FU after discharge from an inpatient setting, which were completed via either telephone calls or in-home visits (Kee et al., 2018; Xuan et al., 2021). By implementing a medication review pharmacy-based TOC team who met with patients prior to discharge from the hospital and again at a one-week FU in the office, the team continued to stay in contact with the patient or guardian for up to 30 days and noted a 34.9% decrease in likelihood of hospital readmission within a 30- day period, which helped reduce 180-day readmission rates by as much as 33.4% (Xuan et al. (2021). A 10% decrease in readmissions was also noted by Liu et al. (2019). Barriers to Appropriate Medication Reconciliation Obstacles to the implementation of successful TOC models were identified in a variety of studies. Historically, barriers to the implementation of efficient programs have been poor engagement with HCP, limited technologies, and insufficient resources (Stolldorf et al., 2020). While barriers specific to the literature review were met with similar impediments, they also identified limited access to patient information, the reluctance of patients to participate in MR review programs or studies, and the inability to contact patients after discharge due to a variety of telephone-related issues, as integral pieces posing threats to productive programs (Albano et al., 2018; Liu et al., 2019). Patient information access. Obtaining access to patient information presents a primary barrier to each patient encounter. A significant barrier can be attributed to the limitation of access to the EHR of patients admitted to healthcare systems outside RPGC which was identified in their previous version of a MR program (Liu et al., 2019). Accessing Medicare and Medicaid patients’ hospitalization utilization data provided some information regarding patients that were admitted UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 18 to community hospitals (Liu et al., 2019). However, this strategy was limited to Medicare/Medicaid patients only (Liu et al., 2019). For patients who received care outside of the home healthcare network, and used private insurance, patient data was not captured in the process and consequently, those patients were not consistently included in the MR process (Liu et al., 2019). For the proposed project, the feasibility of using a similar approach to gain access to patients’ records remains indeterminate. Patient refusal or inaccessibility. Patients’ adherence rate to the TOC process, which includes MR, was recognized as a significant barrier between several studies (Albano et al., 2018; Liu et al., 2019). According to Liu et al. (2019), the inability to contact a large number of patients was directly related to problems of incorrect telephone numbers, disconnected phones, or the patients’ refusal to participate in a MR telephonic interview. Due to these reasons, of a total of 275 phone calls, 40% of the patients included in the study could not be contacted (Liu et al., 2019). A majority of patient calls from pharmacists took an average of 32.3 minutes per phone call (Liu et al., 2019). This barrier was also identified by Albano et al. (2018) who then implemented a call schedule which led to higher connection rates with patients. However, some patients that were added to HCP schedules last minute did not receive a scheduled call from pharmacists prior to their initial FU appointment (Albano et al., 2018). If a call schedule cannot be formulated in advance, it is suggested that patients should be forewarned of FU calls in order to increase participation (Albano et al., 2018). Additional barriers. Several other barriers were briefly noted throughout the studies reviewed. Transportation to in-office visits were identified as an obstacle to meeting FU goals (Kee et al., 2018; Surbhi et al., 2016). Additionally, several studies noted higher copays and lack of prescription coverage as UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 19 a factor in increased incidence of medication error (Kee et al., 2018; Surbhi et al., 2016; Xuan et al., 2021). One note-worthy way to address this potential complication is by utilizing additional team members to perform a prescription cost analysis to identify the most affordable formulary (Xuan et al., 2021). Facilitators Pharmacy utilization. A major benefit noted by many of the studies was that the MR process was pharmacy led. In the literature reviewed, numerous MR processes were led by pharmacy members which included licensed pharmacists, residents, and students (Albano et al., 2018; Kee et al., 2018; Liu et al., 2019; Neu et al., 2020; Surbhi et al., 2016; Tomlinson et al., 2020; Xuan et al., 2021). Among selected articles, several studies found the impact of pharmacist-led MR on medication discrepancies was uncertain due to low-quality evidence (Kee et al., 2018; Redmond et al., 2018; Tuttle et al., 2018). Telephone reminders. Automated telephone reminders for the patients that were successfully enrolled in the study proved to be a facilitator to not only completing a MR, but also lead to increased rates of timely office FU visits (Albano et al., 2018). However, the study also noted they obtained similar results when completing the patient MR between five to ten days prior to their scheduled appointments (Albano et al., 2018). Tomlinson et al. (2020) noted several studies that showed the benefits to phone call interviews such as empowering and improving self-management, patient engagement, and bolstering patient memory regarding medication regimen. Interventions Several central themes were identified toward MR. A major theme identified was telephone-based interventions conducted primarily by pharmacists (Albano et al, 2018; Liu et al., UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 20 2019). Self-management activities, structured medication administration programs, home visits for MR, and timely FU by the HCP were among the other themes that reduced adverse events (Redmond et al., 2018; Surbhi et al., 2016; Tomlinson et al., 2020). Some articles emphasized the importance of HCP assessing medication appropriateness based on medical history, relevant medications, dosing, duplications, and interactions (Redmond et al., 2018; Tomlinson et al., 2020). Outcomes related to MR were more effective when performed during the admission to the hospital, discharge from the hospital, and post-discharge at the community level (Neu et al., 2020: Tomlinson et al., 2020; Xuan et al., 2021). However, one systematic review concluded the evidence for the effect of MR on healthcare utilization was conflicting and potentially made little difference in preventing hospitalization (Redmond et al., 2018). Telephonic-based reconciliation. A common theme found in recent literature is the use of telephone-based reconciliation methods (Albano et al., 2018; Kee et al., 2018; Liu et al., 2019; Surbhi et al., 2016; Tomlinson et al., 2020). By choosing to reconcile medications with patients over the phone, TOC team members were able reach patients quickly after discharge to mutually discuss their medication plan during their transition back to an outpatient care setting; this included providing patients with education or evaluating their adherence to prescribed medications (Albano et al., 2018; Liu et al., 2019; Surbhi et al., 2016). Post-hospital telephone FU appointments allow patients and HCP the opportunity to review medications again, address patients’ concerns, discuss medication adherence, inconsistencies, and any barriers to the patient being successful with their medication regimen (Kee et al., 2018; Liu et al., 2019). Structured medication reconciliation programs. Structured MR requires medication review, concise communication, and exploring other issues that can directly impact relevant data needed for reconciliation. The structured UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 21 reconciliation process can be done in various formats through face-to-face consultations in an outpatient setting, phone interviews, or home visits (Kee et al., 2018; Surbhi et al., 2016). An HCP reviews the drug profile with the patient or caregiver to identify medication-related discrepancies and compares medications provided at discharge from an inpatient setting with the medications the patient is currently taking (Surbhi et al., 2016). The use of a structured program in a specified time frame ensures the timely identification of potential medication omissions, duplications, and interactions (Surbhi et al., 2016). The cause of medication discrepancies can be found at both the system and patient-level (Kee et al., 2018). Automated algorithms can complement MR done by HCP; however, patient-level discrepancies may go undetected (Kee et al., 2018). Follow-up interventions. A variety of modalities for post-hospitalization FU were utilized in the studies analyzed. The manner in which these were conducted included FU appointments in an outpatient setting, telephone calls, and use of home visits to ensure quality continuity of care was achieved and each was identified as an effective communication intervention strategy regarding MR (Albano et al., 2018; Liu et al., 2019; Surbhi et al., 2016; Tomlinson et al., 2020; Xuan et al., 2021). Post- hospital FU appointments allow patients and HCP the opportunity to review medications again, address patients’ concerns, discuss medication adherence, inconsistencies, and any barriers to the patient being successful with their medication regimen (Xuan et al., 2021). Multiple studies also emphasized MR via home visits as an intervention to bridge transition and provide medication continuity (Kee et al., 2018; Surbhi et al., 2016; Tomlinson et al., 2020). Tomlinson et al. (2020) highlighted that further research was necessary to meaningfully engage patients to provide effective medication continuity. A timely FU appointment can assist HCP with identifying UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 22 patients’ overall health status as well as the impact of MR on patient’s health (Kee et al., 2018; Redmond et al., 2018). Summary The TOC from the inpatient to outpatient setting can pose challenges if the patient's MR has not been completed properly. The literature supports a collaborative approach to TOC and MR between pharmacists and other healthcare team members (RNs, physicians, pharmacy students, etc.) (Liu et al., 2019; Neu et al., 2020; Xuan et al., 2021). Collaboration with the pharmacy is imperative in preventing medication errors. Pharmacists have an expert knowledge base in medication indications, dosages, frequencies, interactions, and side effects. Their expertise makes them an integral part of the TOC team. Employing a TOC team whose focus is on having an effective and efficient MR process to ensure patient safety by decreasing MR errors between TOC such as, from the inpatient to outpatient setting, was key for this QI project. Data gathered from the literature synthesis confirmed the importance of TOC teams and reinforced the positive outcomes that result from having them. The conclusions drawn from this data support the QI project and reinforces the importance of establishing a TOC team to oversee the MR process at the RPGC. Methods Ethical Considerations & Protection of Human Subjects Conducting QI studies involving human subjects presents challenges to ethical conduct (White, 2020). When conducting a study that requires human subjects’ participation to gather relevant data, maximum effort is required to protect the rights, physical and mental safety, and privacy of those human subjects. The federally mandated requirement of obtaining Internal Review Board (IRB) approval ensures the procedures and action resulting from this project involving patients met the stringent conduct requirement for IRB authorization. The QI team UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 23 additionally obtained written permission from the stakeholders to implement the MR project at the RPGC (Appendix E). The data retrieval and handling of sensitive patient information was handled by the RPGC staff and was not disclosed to the QI team. This data was de-identified prior to submission to the QI team. All project content was safeguarded on computers with password protection and any tangible documents were kept in locked file cabinets for safekeeping. No additional QI team training was required prior to implementation of the project. Although there were no anticipated concerns with privacy issues or risk to human subjects, Michigan State University Human Research Protection Program (HRPP) and the RPGC facility IRB approval was obtained before initiating the project. Interventions and Data Collection Procedure The goal of this QI project was to improve MR rates and post-hospitalization FU at the RPGC. This type of project was attempted prior to the pandemic, but staff had noted a decline in participation due to changes in priorities associated with COVID-19. The QI team enhanced the original model and implemented notable changes to streamline the process and encourage staff and patient participation. The steps of the implementation process of this project utilized the PDSA cycle, which is explained in the following sections. The project’s timeline can be visualized in Appendix F, Table 3 and the overall budget estimate can be found in Appendix G, Table 4. It is projected this QI project will reduce an average of two medication errors per patient. Surbhi et al. (2016) explains that an average of $293.30 is saved from each medication error prevented by the pharmacist medication management service. The team anticipated an estimated cost saving of $586.60 per patient. Plan. UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 24 The QI team prepared for the execution of the project by meeting with a NP at RPGC over a series of Zoom meetings to discuss the current state of their MR process, as well as achievable goals, potential barriers, and key facilitators. The team then reviewed evidence-based literature to determine current standards of practice regarding MR and ascertain leading initiatives for strengthening patient participation and FU, while limiting medication discrepancies and ADE. Once the gaps of care were identified, the QI team planned to initiate the project by implementing a new spreadsheet for the pharmacy team to utilize when making post- hospitalization calls. The form focused on identifying discrepancies in medications when transitioning from the inpatient setting back to the outpatient clinic. Sample forms were provided to the facility staff for approval and suggestions prior to the start of the project implementation. Do. HCP and pharmacy staff at the RPGC were provided education regarding the use of the new Excel spreadsheet via a voiceover PowerPoint presentation. A voiceover was requested by the clinical staff in lieu of in-person teaching due to the pandemic and to provide the ability to easily teach the new pharmacy residents as they rotated in throughout the project timeline. The spreadsheet was employed to collect information regarding each patients’ hospitalization course, discharge plan, and new medications. When completing the MR, the number of medication discrepancies were identified, recorded, and rectified. Pharmacy team members also scheduled patients for FU visits at this time and the form helped to identify those returning outside of the seven-day return goal. To ensure team synergy and a beneficial collaboration, the QI team provided quick education sessions to the involved staff on the proper use of the MR form and instruction of how to customize sections, if needed, for unique circumstances. This education was repeated for each new pharmacy intern that started throughout the project’s implementation UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 25 dates. Flyers acted as reminders to complete the form with each MR phone call and were placed in several key areas around the clinic. These flyers also included contact information for the clinical site liaison, as well as two of the QI external team, so that someone would be available at all times to answer any questions and help with any concerns. Study. The purpose of this study was to increase MR completion during TOC and collect data in order to measure the medication errors prevented and the number of patients seen within seven days of hospital discharge. Each week, pharmacy staff submitted documentation of completed MR telephone calls with patient information redacted to the QI external team in order to allow for dissemination of data and necessary changes to be made to the implementation process. The data was also reviewed for performance and outcome measures by the QI external team. Feedback was requested from involved clinic staff members to improve the accessibility and ease of spreadsheet use, as well as to determine any unnecessary or burdensome ideas on the form. Act. After completing the first run through of the PDSA cycle, the external team determined a few things needed to be adjusted on the evaluation tool. The first change was to make the document a running document, rather than separate patient data out by month. This was so that no patients were lost between tabs if they were discharged in a month different than the admitted month. A separate column was inserted at the request of the RPGC HCP to account for completed inpatient geriatric consults. Second PDSA Cycle After acknowledging the challenges faced by the implementation team during the first PDSA cycle, the QI external team initiated a second round of implementation by attempting to UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 26 provide live, in-person re-education to the clinic staff. This plan was modified by the stakeholders to a question-and-answer forum held via Zoom with the external team members and the facility stakeholders. Unfortunately, the pharmacy student residents who were part of the implementation process for the facility were not included in the meeting. The external team reiterated they were available via phone or email for any questions and concerns regarding the spreadsheet. Facility implementation team members were advised not to alter the Excel document format or cells without prior consultation from the external team. In conjunction with the provided education, the team members also provided a new copy of the original spreadsheet with functionality and initial rules restored to all cells to be uploaded onto a compatible computer at the clinical site. Measurement Instruments. To properly observe outcomes from the implementation of the QI project, an Excel spreadsheet was created for pharmacy staff to utilize when making post-hospitalization telephone calls to patients. The spreadsheet consisted of three key sections of information: patient data, hospitalization information, and the MR. Several spreadsheet cells were customized to contain dropdown selections in order to create a more efficient, time-saving method of data collection. Pharmacy team members were able to use the dropdowns to insert where patients were admitted to, their discharge deposition, and whether they were able to connect to a patient via phone. The form also provided space to record the number of discrepancies identified with each completed phone call. A free text column was created to provide a place to record any pertinent information detailing the reasons a patient was not progressing through the phases of the improved TOC process. Excel cells pertaining to the time between discharge from an inpatient setting to a FU office visit were also tailored to the goals of the project and would highlight the area red if an UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 27 appointment was made outside the seven-day window. This change was made to help the QI team more easily visualize when the goals were being met and to identify gaps in the project. Results The overarching goal for this project was to increase the MR completion rate at the RPGC to improve upon the identification of medication discrepancies from an inpatient setting to an outpatient clinic and improve upon the seven-day FU appointment rates by utilizing a TOC team and telephone-based MR. The quantitative data was collected on a single, running spreadsheet that was analyzed throughout the three-month study period. A total of 74 discharged patients were recorded on the spreadsheet tool utilized by the clinic; however, only the 18 patients (24.3%) who had MR completed were included in the study. The study measures including medication errors, FU timeframe, and time spent on calls were analyzed. A total of 22 medication discrepancies were discovered during the MR phone calls on 50% of the patients with an average error rate of 1.22 per patient. The identification of these discrepancies saved an average cost of $357.83 per patient. Of the 18 patients reached via a MR phone call, a total of 88.8% scheduled FU visits, however only 38.8% of patients were seen within the seven-day timeframe goal. At the end of the data collection period, 16 of the 18 patients attended their appointment with two patients still outstanding FU. The average length of time to FU was 9.1 days. This data is represented in the tables found in Appendix I. Data retrieved from 50 patients in the three months leading up to the intervention demonstrated a higher rate of patients scheduling a seven-day FU (50%) when compared to the QI group (38.8%). The intervention group demonstrated a 21-day scheduled FU rate of 83.3%, an improvement on the control group 21 day scheduled FU rate of 44%. The use of the new spreadsheet also had a positive effect on the number of errors identified with the intervention UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 28 indicating a 71.8% improvement, as the control group only identified an average of 0.71 errors per patient. Additionally, the QI project improved upon the time spent with each patient. Overall, the pharmacy team spent an average of 18.9 minutes per phone call, which was a drastic improvement over the previous study’s time of 32.3 minutes per call, a decrease of 41.5% (Liu et al., 2019). The implementation of the QI project was successful in several areas such as improvement in identifying medication errors, decreasing the time spent per call, and overall increased scheduling of FU appointments during the TOC from inpatient to outpatient settings. Discussion Implementation Process There were unforeseen delays in implementation because the project required three IRB approvals from different entities (Michigan State University, Wayne State University, and the Detroit Medical Center). Therefore, the implementation of the QI project did not begin until December 6th, 2021. Since different IRB board approvals were needed, there was a duplication of inquiries which resulted in a delayed, drawn-out process. A more streamlined process would have entailed just one IRB approval with endorsements from the other IRB boards. The initial implementation process was scheduled for a three-month period. As a consequence of the delay, the external team, along with faculty advisors, decided to monitor the efficacy of the project over eight weeks. It was unanimously determined by the stakeholders that the goals of the QI project would not be compromised by an abbreviated implementation phase. However, it was acknowledged that more gaps in care may have been discovered with a longer monitoring phase. Barriers and limitations Throughout the implementation phase of the project, several barriers were identified. These barriers not only delayed the implementation schedule, reducing the timeframe for data UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 29 collection, but also affected the quality of the data collected during the first PDSA cycle. The first barrier the team encountered was the prolonged IRB approval process, which included having to receive three IRB approvals. Due to these unforeseen setbacks in the commencement of the project implementation, data collection was delayed by approximately 50 days and the timeframe for collection was decreased from about 20 weeks to 12 weeks. The next significant barrier resulted from precautions due to the COVID-19 pandemic. The clinic opted to do virtual training via Zoom for the two main facility stakeholders in the project, who would then utilize the PowerPoint presentation provided by the external team to educate the rest of the staff on the utilization of the new spreadsheet data collection form. Due to the lack of external team representation for the second round of teaching, the team was unable to address any questions or concerns. Once the project was implemented, no data or feedback concerning the tool during the first few weeks was received and the primary stakeholder in the clinic was off for personal reasons. It appears that in-person implementation training may have been more effective than third party implementation, i.e., facility stakeholders. Once data was made available, the external team noted the spreadsheet had several changes to the original design. Drop down menus had been altered, and some of the functionalities ceased after only a few rows. Additionally, there was a separate note section made available to elaborate on reasons that FU appointments were not made; the column was underutilized and did not clarify barriers to completing the MR. After investigation by the external team and facility stakeholders, it was determined that the computer system used within the clinic to open the original file was not compatible with Excel 2019, so the program defaulted to available options. The defaulted options reduced the usability of the intended project spreadsheet and increased the amount of free text required to complete patient documentation, UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 30 which in turn decreased the overall readability of the document from cells overflowing into neighboring columns. The data returned to the external team for review was limited either due to incomplete documentation by the pharmacy team or inability to reach the patient by phone. Despite the high number of patients discharged home, many data entries lacked complete documentation with only a fraction of the uncompleted cells being attributed to discharge to rehabilitation facilities (n=10), being placed in hospice care (n=5) or expiring (n=4) during the admission. Team members were unable to obtain weekly data updates as originally discussed, which may have identified barriers to be addressed earlier into the implementation process. Communication was only with the lead facility stakeholder and the pharmacist. There was no communication with the ancillary staff members which included schedulers, pharmacy students, and other HCP who were involved with the project implementation. This lack of direct involvement of the external team impeded the training process that could have included instructions, demonstration, and teach- back by primary pharmacy staff to verify proper comprehension of the objectives of the QI process. No feedback was received during the implementation process and the external team was underutilized as a resource throughout the project. This occurred in spite the external team being available; contact information was posted throughout the clinic. Finally, the low rate of patient FU could be attributed to the time the project was implemented. Since the program took place during the winter, patient FU may have decreased due to weather conditions and holiday obligations. One of the original barriers identified on the clinic SWOT analysis was lack of patient transport, which becomes more difficult in the snow and ice and may have played a key role in cancellations or no-show appointments. During implementation of the project, the Omicron variant of the COVID -19 virus was skyrocketing in UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 31 number, and people were advised to limit travel and contact with other people, which may have played a role in affecting the number of patients who successfully completed their FU visits. Implications for Advanced Nursing Practice For years, patient safety as it relates to medication error prevention has been a main focus for all HCP. As demonstrated by the IOM (2000), nearly 100,000 Americans had deaths attributed to medical errors annually during hospitalization and 1 in 131 occurring in the outpatient setting. The use of a quality, established MR program can help to expose errors made during patients’ TOC between different levels of healthcare. While previous studies have determined that TOC MR teams have the potential to identify errors in over 80% of charts examined, there are still many barriers to implementing a well-rounded MR program (Albano et al., 2018; Surbhi et al., 2016). Healthcare professionals wishing to initiate programs within their individual settings must work to identify both patient and clinic-specific barriers. By enacting effective MR programs, HCP have the opportunity to positively affect the number of errors that reach patients throughout their TOC. Overall, the use of a MR process has the potential to be a considerable source of revenue for any outpatient healthcare clinic, which may incentivize clinics to push for the use of post- hospitalization phone calls to schedule FU appointments and review medications. HCP are able to bill Medicare using code 99496 for any patient seen within seven days of hospital discharge or code 99495 for those seen within 14 days with reimbursement values of $237.11 and $175.76 per patient, respectively (HealthViewX, 2021). This substantial increase from billing codes 99211- 15 that are regularly used in the clinic provides approximately an extra $100 on average per patient (Binder Dijker Otte United States, 2021). The TOC presents an important opportunity for QI for the APRN. The APRN can play an essential role during TOC that spans the hospitalization of patients to primary care. However, as UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 32 exemplified by the deficiency of patient participation in this QI project, the compartmentalization of the TOC process can create obstructions to the implementation of a comprehensive TOC. According to Kansagara, Chan, Harmon, and Englander (2013), multicomponent strategies to create a smooth and safe transition of care from in-hospital to primary care setting includes:  fostering patient engagement and empowerment  guiding patients in medication management which includes a medication reconciliation  timely follow up clinical visits  a dedicated and consistent transition coordinator that has the competency to provide resources and education to the patient across the spectrum of primary care management The fragmentation of healthcare, along with health disparity/inequity and the lack of access to healthcare in the US, greatly impacts less affluent OA similar to the targeted population for this QI project (AHRQ, 2021). Despite spending a significant amount of healthcare dollars, when compared to several other developed countries, the US has among the lowest life expectancy rates, highest chronic disease rates, highest hospitalization, and avoidable death rates (Commonwealth Fund, 2022). The role of a dedicated transition coordinator with the availability, education, and competencies to manage or coordinate all aspects of TOC would be efficiently assigned to the APRN. Timely primary care FU is additionally considered a key strategy to decrease rehospitalization, as 50% of patients readmitted within 30 days of initial hospital discharge do not receive FU prior to readmission (Jackson, Shahsahebi, Wedlake, & Dubard, 2015). UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 33 Therefore, utilization of TOC to encourage patients to attend timely primary care FU can provide meaningful incentive of reducing rehospitalization. The utilization of TOC teams can identify gaps in care, psychosocial and economic factors, integrate medication management, encourage participation of care partners, and timely FU with HCP (Noel, Messina, Hou, Schoenfeld, & Kelly, 2020; Thomas-Hinkel, Turner, & Freda, 2018). Sustainability Plan For a QI project to be sustainable, it has to be meaningful, useful, and pragmatic (Mortimer et al., 2019). The patient outcomes as a result of QI project implementation need to be analyzed for social, environmental, and economic impacts. Based on strengths and limitations observed during the implementation of the QI project, the RPGC could successfully sustain the utilization of the TOC team for effective outcomes related to reducing medication errors and improving seven-day FU. However, barriers and limitations must be appropriately addressed and thorough education should be provided to existing and new TOC team members, as the team members do change. Successful strategies include improved TOC team training, permanently assigning TOC team members, and emphasizing responsibilities and accountability from team members (Lawson, Weekes, & Hill, 2018). Effective leadership support appears essential for the sustainability of QI. Frequent PDSA cycles and an improvised data collection tool may be needed to achieve the maximized identification in MR errors and improve seven-day FU. Even though there were significant obstacles faced during the implementation, the project provides insight towards the solutions. Some of the limitations encountered during the project were unrelated to the outpatient primary care facility and therefore should not be a factor in the sustainability of the improvement. If the project was initiated and implemented by RPGC UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 34 internal staff members, it may have had higher chances of success assuming improved communication, training, team support, and timely PDSA FU (Kiran et al., 2019). Recommendations As demonstrated by the implementation of this project, the utilization of the TOC team has the potential to improve patient safety. A beneficial intervention could be completed after addressing obstacles involving patient engagement and healthcare systems practice. This project sought to reduce medication errors and improve seven-day FU. Such initiatives can add value towards achieving the triple aim goals; improving patient health, reducing cost, and improving patient satisfaction (IHI, 2022). Recent studies suggest that the unimodal approach of using only MR interventions during transitions of care to improve patient safety could have a limited impact on patient outcomes (Anderson et al., 2019). This is not to suggest that MR has no value in the real-world clinical care of patients. MR before treatment management that includes pharmaceutical intervention is necessary for patient safety (Lehnbom, Stewart, Manias, & Westbrook, 2014). However, implementing multi-focal approaches to TOC, such as patient and caregiver/care partner education and focusing on patient empowerment, could positively impact healthcare utilization. One of the essential roles in NP practice is to foster patient engagement that results in person-centered care. Encouraging a person to be an active participant in their healthcare is a primary goal of a person-centered healthcare model (National Patient Safety Foundation’s Lucian Leape Institute [NPSF], 2014). An essential component of increasing patient engagement involves improving health literacy. Health literacy is necessary for patient empowerment, resulting in increased patient engagement (NPSF, 2014). When patients have improved health literacy, they can make informed decisions and be active participants in their own healthcare. Allowing patients to have autonomy in their healthcare results in positive personalized and UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 35 patient-specific outcomes. Improving health literacy and patient empowerment gives patients a sense of control over their healthcare and lives (Finley, 2015). With improved health literacy and patient empowerment, the patients’ understanding of the purpose and benefits of participation in MR and timely FU could have improved patient and family engagement. A fundamental goal in healthcare is decreasing healthcare inequities common among the RPGC patient population (CDC, 2022). Meeting these disparities could be attained by the utilization of comprehensive, patient- and family-centered TOC. Ideally, it is beneficial for OA to partner with family members in their healthcare decision-making (National Academies of Sciences, Engineering, and Medicine, 2016). This would theoretically result in increased FU and reduced risk of complications stemming from adverse medication events (NPSF, 2014). Meeting these disparities could be attained by the utilization of comprehensive, patient- and family-centered TOC. Therefore, any healthcare literacy and empowerment process should include the patient's family members and care partners. Patient discharge education should begin on admission to the hospital through collaboration with inpatient HCP who can ensure that patients are receiving medication and reconciliation education while hospitalized and at discharge. Providing patients with educational materials that are at a fourth to sixth grade reading level, to ensure comprehension, is recommended (AHRQ, 2019b). HCP should limit discussions to five main points written in layman’s terms and utilize imagery, teach-back methods, and physical tools to connect with patients with all types of learning styles (AHRQ, 2019b). Additionally, HCP should assess the learner’s mental state, current stressors, and illnesses prior to providing education (AHRQ, 2019b). UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 36 The implementation of TOC teams can improve patient safety, however, there are still outstanding inquiries on how exactly utilization of the TOC team, reducing medication errors, and improving seven-day FU can reduce rehospitalization, thus reducing healthcare cost and improving patient satisfaction. For future TOC studies, it would be beneficial for the external team to be involved with the internal TOC team and responsible for making the MR phone calls and FU appointments. A patient-centered longitudinal study of the QI project implementation could provide a clearer understanding of the outcomes. Conclusion Changes made to medications during the patient’s hospital stay and delay in post-hospital FU by primary care providers can potentiate medication errors and harm patients. Although implementation can be challenging, the utilization of the TOC team has the potential to improve patient safety but requires increased patient participation and staff commitment. The goal of the project was to identify medication errors by utilizing a telephone-based TOC team and to improve upon the number of patients seen in an OP clinic visit within seven days of hospital discharge. The interventions of this QI project did demonstrate significant statistical support for the effectiveness of a TOC MR on improving the identification of medication errors and overall FU appointments scheduled at the RPGC. The project did not positively impact the number of patients seen within seven days. Several barriers were a factor in the outcome of the QI project. The implementation time for the project was limited, which was reflected in the quantity and quality of the data collected. Medication errors and untimely FU can have serious negative consequences, which can often be avoided by using TOC teams. The results of the project did not allow for the external team to ascertain whether the lack of improvement in seven-day FU rates was attributed to the utilization UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 37 of a TOC team or the ineffectiveness of the implementation tool. Although the seven-day FU goal was not met, the intervention group did demonstrate improved 21-day FU, which would suggest that a longer implementation phase could provide data to support improved FU rates. Further studies should also be completed to assess interventions to promote timely FU. 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Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: A systematic review and meta-analysis. Journal of American Medical Informatics Association, 24(2), 413-422. doi:10.1093/jamia/ocw145 Prusaczyk, B., Fabbre, V., Morrow-Howell, N., & Proctor, E. (2020). Understanding transitional care provided to older adults with and without dementia: A mixed methods study. International Journal of Care Coordination, 23(1), 14-23. doi:10.1177/2053434520908122 Redmond, P., Grimes, T., McDonnell, R., Boland, F., Hughes, C., & Fahey, T. (2018). Impact of medication reconciliation for improving transitions of care. Cochrane Database of Systematic Reviews, (8). 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(2021). 2021 Hospital national patient safety goals. Retrieved from simplified-2021-hap-npsg-goals-final-11420.pdf Thomas-Henkel,C., Turner,S. & Freda, B. (2018). Opportunities to enhance community-based medication management strategies for people with complex health and social needs. Retrieved from https://www.chcs.org/resource/opportunities-to-enhance-community- based-medication-management-strategies-for-people-with-complex-health-and-social- needs/ Tomlinson, J., Cheong, V. L., Fylan, B., Silcock, J., Smith, H., Karban, K., & Blenkinsopp, A. (2020). Successful care transitions for older people: A systematic review and meta- analysis of the effects of interventions that support medication continuity. Age and Ageing, 49(4), 558-569. doi:10.1093/ageing/afaa002 Tuttle, K. R., Alicic, R. Z., Short, R. A., Neumiller, J. J., Gates, B. J., Daratha, K. B., … Corbett, C. F. (2018). Medication therapy management after hospitalization in CKD. 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Ochsner Journal, 20(1), 16-33. doi:10.31486/toj.20.5012 Wojciechowski, E., Pearsall, T., Murphy, P., & French, E. (2016). A case review: Integrating Lewin’s Theory with Lean’s System Approach for Change. The Online Journal of Issues in Nursing, 21(2), 4. doi:10.3912/OJIN.Vol21No02Man04 World Health Organization. (2016). Transitions of care: Technical series on safer primary care. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/252272/9789241511599- eng.pdf Xuan, S., Colayco, D., Hashimoto, J., Barca, J., Dekivadia, D., Padula, W. V., & McCombs, J. (2021). Impact of adding pharmacists and comprehensive medication management to a medical group’s transition of care services. Medical Care, 1(59), 519-527. doi:10.1097/mlr.0000000000001520 UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 46 Appendices Appendix A Table 1 SWOT Analysis Matrix of Rosa Parks Geriatric Center Strength Weakness 1. Well established, patient-centered primary care organization 1. Limited knowledge regarding MR in primary care setting 2. Stakeholders at primary care are receptive to QI project 2. Limited access to patient data 3. Dedicated community member & faculty available to 3. Availability of advanced technology (for communication, data coordinate & guide the project extraction) 4. Group members knowledge & experience with QI projects 4. Financial constraints, limited resources 5. Easy access to patients & other community stakeholders 5. Significant hierarchical process for specific QI project 6. Explore best practices related to preventing adverse events 6. Transportation burdens for focused patient population 7. Ability to collaborate with IDT members Opportunities Threats 1. Introduce improved MR process 1. Barriers to accessing patient information 2. Educate patients &/or caregivers on MR to prevent medication- 2. Resistance from IDT members related adverse events 3. Reduce adverse events related to medication errors 3. Patient adherence or refusal to participate 4. Improve post-hospitalization visit adherence 4. Inability to complete the project within a one-year timeframe 5. Decrease hospital readmission rates/ED visits 5. Lack of access to integrated EHR/hospital utilization data 6. Ability to explore best practices related to preventing adverse events 6. Potential attitudes/resistance towards students performing QI project 7. Project abandonment secondary to internal & external factors (e.g., COVID-19 pandemic) UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 47 Appendix B Figure 1 Fishbone Diagram UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 48 Appendix C Figure 2 PDSA Model for Improvement UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 49 Appendix D Table 2 Literature Synthesis Table Author Purpose of Relation to Implications for (Year) Title LOE* Research Framework Results Project practice Albano et al. Discrepancies RA** To determine A student- A total sample Identifies the gaps MR prior to (2018) identified through the prevalence conducted study size of 656 in outpatient care clinical visits a telephone- of medication aimed at patients were & focuses on benefit patients based, student-led errors after the improving rate of used & 84.7% amendment by by identifying initiative for MR use of a medication reviewed patient connecting with discrepancies in ambulatory telephone- discrepancies using profiles were patients to within patient psychiatry based MR a telephonic found to have at determine medications. service system to speak least one potentially Identifies the with patients one medication harmful importance of use week prior to discrepancy with medication of a pharmacy- initial clinic visits. a total of 1416 interactions & based team to The call team discrepancies discrepancies. conduct MR included student identified. reviews. pharmacists, Discrepancies pharmacy fellows, included and a psychiatric deletions clinic pharmacist. (38.6%), The phone calls additions focused on (38.9%), & dose identifying changes medication (22.5%). The additions/deletions, study was able to changes to doses, reach 99% of medication patients but interactions, & use identified of supplements. waitlisted UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 50 Medications were patients who updated in the were added on a EHR as day prior to their appropriate & the appointment as a team identified potential gap in cost & adherence practice. issues with each patient. Corbett et al. Nurse identified QE*** A sub-study of Researchers used 94% of patients Illustrates the Supports the need (2010) hospital to home & RA a larger RTC the Medication surveyed was extensive for structured and medication that analyzed Discrepancy Tool found to have at problems with comprehensive discrepancies: data to determine if least 1 medication errors TOC to avoid Implications for exclusively there were any discrepancy in occurring during adverse events improving from the discrepancies from medication list. TOC. and medication transitional care. intervention hospital discharge errors in patients arm of the lists and the transitioning from primary study. medication list the hospital to the The purpose patient reported community. was to evaluate following. the impact of medication errors that occur during TOC as identified by RNs interviewing 101 patients. Kee et al. A review of SR^ Researched Grading of LOE & Intervention Noted different Established there (2018) interventions to literature data strength of methods methods of is an opportunity reduce for studies that recommendations included phone implementation. for IDT members medication examined gaps were conducted interviews; home mostly face-to- to participate or discrepancies or of patient care using the Strength visits, & in face interviews coordinate with UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 51 errors in primary during of person immediately prior the MR process or ambulatory transitions Recommendation consultation to in-office FU in the primary care setting from in- Taxonomy, a new interviews visit; and care setting. during care hospital to grading scale conducted telehealth Noted need to transition from primary care. created to establish immediately visit/interviews focus on TOC hospital to Focused on the a standard of prior to FU that resulted in during inpatient primary care rate incidence, quality, quantity of office visits. The the most to ambulatory impact of consistency of article noted favorable care setting to medication evidence there was little outcomes. reduce discrepancy, synthesized in body of evidence a Discovery of medication errors errors, & the scientific studies that confirms medication that frequently impact of that focuses on suggestion that discrepancy, & occur following interventions evidenced-based MR process appropriate discharge into the such as MR to medical practices resulted in medication home/community improve that impact patient measurable changes. setting. patient outcomes. favorable patient outcomes. outcomes (such as decrease in 30-day hospitalization & laboratory findings) & there is a need for future studies to validate this commonly accepted theory Khalil et al. Professional, SR Determine if RCT where The authors Provides insight Helps understand (2017) structural and professional, healthcare could say with related to current the importance of organizational structural, and professionals moderate to low professional & addressing the interventions in organizational offered certainty that organizational current primary care for interventions community-based primary care interventions used interventions at are more services. 30 interventions to to prevent adverse this QI project UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 52 reducing successful than studies with a total decrease events related to organization. A medication errors. standard care of 169,969 patients preventable medication errors. comparison can in reducing with different medication Likely a need for be made with the preventable approaches to errors had little structural interventions prescription reducing to no effect on interventions & mentioned in the mistakes by medication errors. decreasing ED new innovative study & the primary 3 writers extracted visits, interventions at primary care healthcare data hospitalization, professional & organization. practitioners. independently. or mortality. organization level Hospitalization, to reduce adverse ED visits, & events. mortality were the 3 outcomes studied. Data presented using risk ratios with a 95% confidence range. The GRADE method was used to determine the certainty of the evidence. Liu et al. Post-discharge RA To evaluate An IDT in an The authors Demonstrates the To provide safe & (2019) medication telephonic MR urban clinic could say with importance of effective care to reconciliation: methods developed a TOC moderate to low timely & accurate patients, Reduction in program that certainty that MR to prevent medications need readmissions in a utilized telephonic primary care adverse effects to be reviewed geriatric primary MR after hospital interventions to from affecting the after any inpatient care clinic discharge. Nurse decrease patient. visit to ensure no case management preventable medication notified the team medication interactions are of discharges, & errors had little present, that UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 53 pharmacy team to no effect on patients have would call patients decreasing ED access to the within 48 hours of visits, appropriate discharge. The hospitalization, medications after phone call was or mortality. discharge, & that used to reconcile timely FUs are medications, scheduled. ensure prescription access, identify any medication issues, and schedule a FU visit in the clinic within 7 days. Medication records were updated, refills provided, & necessary changes were made for interacting medications. Naylor & Transitional Care: SR To understand An archival review Three strategies Will serve as Revealed large Keating Moving patients the TOC of TOC models to were determined guidance of gaps of care that (2008) from one care models explore the results to improve setting project existed for setting to another. experienced by of strategies used quality of patient goals and patients and patients and during TOC of care: improving designing a TOC family caregivers. family older patients. This patient access to model to meet These caregivers in was done to assess community standards of care. deficiencies U.S. impact on patient resources; resulted in poor care due to TOC improving and patient outcomes, models. expanding TOC unmet needs, services during high transitions; and rehospitalization UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 54 improving rates and lower handoff of patient pertinent patient satisfaction. This information and archival article treatment plans was part of a during TOC. body of evidence that elucidated the need for improvement of TOC methods in older chronically ill patients. Neu et al. Impact of QE To evaluate the Study conducted at The study Study provides Demonstrates the (2020) pharmacist impact of Ascension St. John included patients evidence in importance of involvement in pharmacy-led Hospital in Detroit who were support of a having a heart failure heart failure MI. A pre-post admitted with a pharmacy-led pharmacy-led transition of care (HF) TOC design was used to HF diagnosis TOC team. This TOC team to programs on determine between March is important for decrease 30-day HF if having a 1, 2016, and this project readmission rates readmission pharmacy-led TOC August 31, 2018. because it will in HF patients. rates. team would 872 patients involve The evidence decrease the were screened, collaborating with supports having a readmission rate 209 patients pharmacy & pharmacy-led for HF patients. 3 were excluded articles like this hospital-based main interventions leaving 663 one support why MR TOC team, were included in patients included working with which provides the study: in the study. Of pharmacy is specific education admission MR, those patients beneficial for the to HF patients. discharge MR, & 330 were the MR process & to This is beneficial patient or caregiver control group & have on this TOC for decreasing the education on HF 333 were in the team. Important 30-day admission medications via intervention to note the most rate for HF verbal group. The 30- commonly patients. UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 55 communication as day readmission needed well as provided rate for HF interventions written education patients in the were all materials. control group medication was 57 patients related & likely (17.3%). The 30- prevented day readmission medication errors, rate for the omissions, & intervention adverse events group was 35 related to patients (10.5%). medications. Common interventions needed were dose titrations (7.5%), adding additional medications (11%), discontinuing mediations (6.6%), & avoiding medication duplications (2.7%). Prusaczyk et Understanding QE & A mixed The framework for Determined that Clarifies Clarifies al. (2020) transitional care RA method study this quasi- different traditional roles traditional roles provided to older utilizing experimental study providers play of providers of providers adults with and provider was not defined by different roles during TOC and during TOC and without dementia: interviews authors but during the TOC identifies barriers examines any A mixed methods (qualitative) to methods of process and encountered barriers to study. guide medical analysis resemble these steps differ during transitions providers UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 56 chart reviews the Framework between patients assuming (quantitative). Study analysis with and without additional tasks to The purpose method. dementia. augment TOC was to services. understand the current process used to deliver health care during TOC. Redmond et Impact of MR for SR To analyze Only RCT were Researchers Provides some Demonstrates al. (2018) improving TOC selected chosen. 2 review found 25 evidence on need of further studies about authors screened randomized impact of MR. studies with high how MR for titles & studies with a Authors identify certainty related affects abstracts, total of 6995 that pharmacist- to impact of MR medication determined study individuals. mediated on preventing discrepancies, eligibility, assessed With poor interventions adverse events, healthcare bias risk, & certainty of the were specifically rehospitalizations, utilization, extracted data. The available not helpful. & use of EDs. & patient- results of evidence, Therefore, a QI related individual studies reconciliation project will outcomes in were combined to may have had require further patients who produce summary minimum to zero exploration to receive it estimates with a effect on suggest during care 95% confidence avoidable pharmacist- transitions interval. For each adverse mediated MR as versus people pooled outcome, medication one of strategies who don't. the GRADE events. Evidence for improving method was used for effect of clinical outcomes to assess the MR on such as evidence. healthcare usage preventing was conflicting, adverse events, & probably ED utilization, & made minimum rehospitalization. UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 57 difference on unexpected rehospitalization. Rustad et al. Older patients' QI^^ Explore the Interviews of 14 TOC is complex The targeted Older patients are (2016) experiences older patients older patients (≥80 in OA who population at often reluctant to during care experience years of age) to require direct RPGC is older "interfere" with transition during explore the invitations to population and healthcare, transitioning experience of participate in this will require instead taking a from hospital transitioning from own healthcare special more passive role to community hospital setting to planning due to consideration to in own health. healthcare in the expectations of empower and This could be due community roles that older engage patients to to a legacy of a patients have as participate with more patriarchal a result of healthcare structure of history of planning. healthcare in patriarchy in earlier years. medicine. Lack of engagement may not necessarily be due to lack of healthcare literacy or interest. Stolldorf et Implementation QQ^^^ Described the Survey of the The study Described various Staff buy-in can al. (2020) of sustainability sustainability leaders of the 5 revealed strategies used to facilitate QI of a medication of a QI change hospitals that hospitals execute projects. reconciliation using the implemented QI successfully interventions that Supporting toolkit: A mixed MARQUIS change using the implemented QI can be utilized in strategic staff methods Toolkit. MARQUIS toolkit. change using a the proposed QI empowerment evaluation. variety of project. that can lead to strategies. Lack ownership from of staff buy-in staff and resulted in UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 58 significant prioritization by barriers to QI staff. implementation, such as low prioritizing the improvement process. Surbhi et al. Drug therapy RA Analysis of Study conducted to 374 participants Identifies the Pharmacy-based (2016) problems and drug therapy evaluate enrolled in the period of care teams have been medication discrepancies effectiveness of SafeMed transitions as a beneficial to the discrepancies during care SafeMed care program. The key care gap area prevention of during care transitions transitions program with a high drug-related transitions in among patients program. Patients identified potential for discrepancies in super-utilizers with multiple were enrolled in therapy error. Pharmacy- patient charts comorbidities the program during problems in based teams occurring & their hospital 80.7% of cases utilized both face- throughout care polypharmacy admission. & 75.4% to-face & transitions. Medication records discrepancies. telephonic were reviewed at The most interventions to the bedside with frequently reconcile pharmacists to aid identified drug medications in identifying therapy appropriately. errors. Upon problems discharge, patients included not were provided with obtaining a personalized medications, medication list underuse, & with administration incorrect dose or instructions & duration. The education program helped regarding purposes prevent costs of & potential side more than $290 effects. Pharmacy per problem UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 59 technicians identified. The reconciled study recognized medications at those with home visits in multiple order to recognize comorbidities discrepancies with were at the outpatient highest risk for medications which discrepancies. included omissions, duplications, & dosing errors. Between each home visit, the technicians called patients to help recognize barriers to medications, adherence rates, & potential therapy issues. After completion of 2 home visits & 2 FU calls, patients were given a finalized medication record. Tomlinson Successful care SR & Reviews A database search Successful Considered The study et al. (2020) transitions for MA+ interventions for RCT. Older transition of care strategies reinforces the older people: A that help older persons, is likely possible including MR to importance of systematic review patients interventions with prevent adverse MR as one and meta-analysis transition from during interventions events. effective strategy of the effects of one type of hospitalization, that bridge the to prevent UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 60 interventions that care to another post-discharge transition. Self- adverse events in support by keeping activities that management patients medication their support medication activities, discharged from continuity medications continuity were telephone the hospital. consistent. among selection follow-up, & criteria. 24 studies MR were all with total 17,664 statistically participants. linked to fewer Reviewed hospital outcomes related readmissions. to hospital readmissions, safe medication use, & quality of life. Random-effects meta-analysis was used to pool the outcomes. Tuttle et al. Medication RCT Effects of MR Chronic care Concluded that Another Provided insight (2018) therapy following model & algorithm pharmacy led perspective on to the benefit of management after hospitalization of implementation MR did improve how effective the pharmacy hospitalization in for CKD was the "5As" patient proposal of MR involvement with CKD: A strategy. Assessed adherence rates to improve patient patients to randomized 141 patients on the but did not outcomes will improve clinical trial the impact of ultimately have the desired medication rehospitalization improve patient impact. Also adherence. The rates of patients outcomes. An looked at long study challenges discharged from initial term interventions the commonly hospital with a improvement in that can provide held belief that CKD diagnosis the intervention strategies to guide increasing without group at the this design for medication hemodialysis. onset of the sustainability. adherence & Patients were study, but when appropriate UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 61 assessed with a the study prescribing alone MR and concluded with will improve assessment of the final MR patient outcomes. medication interview, the Concluded that adherence 3 times rates of more during the post hospitalization comprehensive discharge phase. for the medication The metric used to intervention programs should evaluate success of group compared be studied to program was to the usual care evaluate rehospitalization group was improved patient rates. insignificant at outcomes. only 1% improvement rate. World Transitions of SR A technical Review of Examined the This report Cumulative Health Care: Technical report published peer- gaps in care and provides landmark report Organization Series on Safer series/literature reviewed literature the impact on historical of 9 monographs (2016) Primary Care review to and interviews of patient safety evaluations of examining all identify gaps international due to these gaps of care aspect of patient in health care experts in the deficiencies. The encountered care. TOC has that negatively medical field report offered during TOC and been determined impact patient regarding TOC strategies provides a to be a high safety. was used to create successfully foundation of priority process this series. used by experts evidence to guide that can result in to avoid adverse future approaches poor patient events during to effective and outcomes and TOC. safe TOC. increased healthcare cost through increased hospitalization. Xuan et al. Impact of adding L++ The purpose is The effectiveness Included 13,256 This study Supports adding a (2021) pharmacists & to evaluate the of adding Synergy hospital supports adding pharmacy-led UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 62 comprehensive impact of Pharmacy discharged adult pharmacy to the TOC program & medication having a TOC Solutions to the patients for 30- TOC team to demonstrates management to a team lead by TOC is evaluated. day readmission decrease hospital decreases of medical group’s pharmacists. Adding analysis & readmission rates. hospital TOC services The research pharmacists 10,740 Adding pharmacy readmission rates will determine allowed the discharged for also decreased at 30 & 180 days. if the evaluation of 180-day MR errors. pharmacist- patients’ analysis. Adding provided TOC medication orders the TOC service will before discharge & program reduced decrease assesses the the 30-day hospital appropriateness of readmission risk readmission the medication, by 34.9% & rates. safety risks, 180-day barriers to patient readmission by adherence, 33.4%. effectiveness of the medication, & the ability of the medication to be taken by the patient. An individualized plan of care was created & focused on the patients' goals of therapy. Pharmacy followed the patient after discharge, made sure they had access to medications post- UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 63 discharge, & reevaluated medications at a 1- week post- discharge appointment. Pharmacists followed patients for 30 days post- discharge & maintained communication with patients to ensure there were no medication problems & FU on medication effectiveness & appropriateness. *LOE= level of evidence **RA= retrospective analysis ***QE= quasi-experimental ^SR= systematic review ^^QI=qualitative interview ^^^QQ = Qualitative/Quantitative survey +MA= meta-analysis ++L= longitudinal Running Head: UTILIZATION OF TRANSITIONAL CARE TEAM-FINAL 64 Appendix E Running Head: UTILIZATION OF TRANSITIONAL CARE TEAM-FINAL 65 Appendix F Table 3 Gantt Chart UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 66 Appendix G Table 4 Project Budget Covered Period: September 2021 to December 2021 (13 weeks) Personnel Expenses Total Expense Type of Expense Source per Line Item Notes Chelsea, RN In-kind $ - 90 hours of gratis labor Kristen, RN In-kind $ - 90 hours of gratis labor Sam, RN In-kind $ - 90 hours of gratis labor Tanya, RN In-kind $ - 90 hours of gratis labor Dr. Binns-Emerick, DNP RPGC $55.05 x .3FTE hours x 13 weeks (Clinical site expert) $ 8,587.80 Employee RPGC Pharmacist $ 9,409.92 Employee $60.32 x .3FTE for 13 weeks Pharmacy intern In-kind $ - .3FTE hours per week of gratis labor RPGC Registered nurse $ 4,000.88 Employee $38.47 x .2FTE RPGC $17.75 x .2FTE 104 hours x weeks Medical office assistant $ 1,846.00 Employee Mean salaries retrieved from the U.S. Bureau of Labor Statistics (2021). MISCELLANOUS EXPENSES Office supplies In-kind $ 100.00 Total $ 23,944.60 Expenses Estimated cost savings per patient $ 586.60 2 medication errors @ $293.30 per error Estimated cost saving from reduced medication errors. UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 67 Covered Period: January 2022 to April 2022 (13 weeks) Personnel Expenses Total Expense Type of Expense Source per Line Item Notes Chelsea, RN In-kind $ - 90 hours of gratis labor Kristen, RN In-kind $ - 90 hours of gratis labor Sam, RN In-kind $ - 90 hours of gratis labor Tanya, RN In-kind $ - 90 hours of gratis labor Dr. Binns-Emerick, DNP (Clinical RPGC $ 8,587.80 site Employee $55.05 x .3FTE hours for 13 weeks expert) RPGC Pharmacist $ 9,409.92 Employee $60.32 x .3FTE hours for 13 weeks Pharmacy intern In-kind $ - .3FTE hours per week of gratis labor RPGC Registered nurse $ 4,000.88 Employee $38.47 x .2FTE RPGC Medical office assistant $ 1,846.00 $17.75 x .2FTE hours per week x weeks Employee Mean salaries retrieved from the U.S. Bureau of Labor Statistics (2021). Miscellaneous expenses Office supplies In-kind $100.00 Total Expenses: $ 23,944.60 Total Combined Expenses: $ 47,889.20 Estimated cost savings per patient $ 586.60 2 medication errors at $293.30 per error Estimated cost savings from reduced medication errors. Total cost savings for 50 patients (100 medication errors) $ 29,330.00 UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 68 Appendix H Table 5 RPGC MR Form Consult MR Patient 2-Week Post MR Call 30 day Discharge Discharge Discharged Time Spent # of Follow up Total Days to # of Admitted service Home Care Completed Attended FU Visit Call Complete readmit Diagnosis Date To (Mins) Discrepancies appt date FU Discrepancies contacted Date appointment Date Date DMC No Yes CAD 7/18/2021 Home No 7/20/2021 20 2 7/25/2021 Yes 7 8/10/2021 6/30/2021 7/12/2021 12 0 0 0 0 0 0 UTILIZATION OF TRANSITIONAL CARE TEAM IN PRIMARY CARE 69 Appendix I Table 6 Pre-intervention data Month Number of patients Total FU scheduled FU scheduled within seven days September 2021 5 2 0 October 2021 24 10 3 November 2021 21 10 8 Table 7 Intervention data Month Total number MR Total FU FU Percent Percent of of patients completed scheduled scheduled attendance overall FU discharged during MR within seven- within seven attendance from hospital day goal days (extended to 21 days) December 2021 22 5 5 1 100% 80% January 2022 31 7 5 3 100% 100% February 2022 23 6 6 3 100% 83.3%