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Featured Clinical Topic: The Pharmacist’s Role: Transition of Care for Heart Failure Patients

06 Oct 2021 4:35 PM | Anonymous

By: Sarah Schriewer and Megan Smith, PharmD Candidates 2023; St. Louis College of Pharmacy at University of Health Sciences and Pharmacy in St. Louis

Mentor: Roxane Took, PharmD, BCACP; Assistant Professor, Department of Pharmacy Practice, St. Louis College of Pharmacy at University of Health Sciences and Pharmacy in St. Louis; Gateway Apothecary


The increased prevalence of heart failure readmissions proves costly for both hospital health systems and patients. More than 20% of hospitalized heart failure patients will return for readmission within a 30-day period.1 Within the last ten years, the Centers for Medicare and Medicaid reduced reimbursement to health systems with excessive 30-day readmission rates in order to curb the climbing occurrence and associated costs of these readmissions.2 This was done to remove incentivizing procedures that may lessen the quality of patient care.3 Many hospitals have established transition of care (TOC) teams composed of various healthcare personnel following this reimbursement limitation.4 The inclusion of the pharmacy profession on the TOC team remains essential, as confirmed by numerous studies that examined the purpose, involvement, and outcomes related to pharmacy specifically. Through performance and accountability measures, the Joint Commission closely examines the efforts of hospitals to improve heart failure patient outcomes.5 Pharmacists play an integral role in improving standards for TOC in heart failure patients.

Clinical Trial Review

A single-center, retrospective, quasi-experimental study regarding the impact of pharmacy involvement in heart failure transitions of care found that 30-day readmission rates significantly decreased with the integration of a pharmacist-led TOC team. These TOC services included medication reconciliation performed by the pharmacist, pharmacy residents, or pharmacy interns upon admission and discharge; and patient education with verbal and written components. The majority of patients transitioned from the hospital setting to home, where the patient and caregivers would greatly benefit from written educational materials provided to patients in the intervention group. The study, conducted at Ascension St John Hospital in Detroit, Michigan, focused on 663 patients admitted to cardiac medical floors with a primary or new diagnosis of heart failure. The 333 patients in the intervention group received the pharmacy-led TOC services, whereas the 330 patients made up the control group received TOC services led by other professions. The most common interventions resulting from medication reconciliation involved addition of a medication, dose titration, treatment discontinuation, and duplication avoidance. A total of 17.3% of control group patients had a heart failure readmission within 30 days following discharge whereas only 10.5% of patients in the intervention group experienced a hospital admission within the 30-day window post-discharge.4

Cohort Study Review

A monocenter, retrospective, observational cohort study at the Veterans Administration Tennessee Valley Healthcare System determined the outcomes associated with heart failure patient follow-up interviews performed by a clinical pharmacy specialist (CPS). This study was performed to consider the value of  a CPS, especially during a provider shortage. Cohorts were composed of Advanced Heart Failure Clinic (AHFC) patients within this VA health system. Researchers hypothesized that patients receiving care from a CPS would have similar results in comparison to patients following-up with a “familiar provider.” A novel clinical pharmacy telephone clinic was a valuable component in managing medications and reducing 30-day readmission rates. Patients who received the care provided by the CPS had a 10.9% readmission rate. In contrast, patients without the clinical pharmacy interventions had a 12.9% readmission rate within 30 days. Clinical pharmacy specialists in the Veterans Administration health setting are capable of performing more advanced practitioner care, such as limited prescribing and other patient care authorities. This study provides an interesting outlook on the expanding world of pharmacy practice and the impact pharmacists can make on patient outcomes.1

Management of Implementation

When implementing TOC teams, it is important to consider the additional time commitments that the pharmacy team will have to make and the best way to spread the added workload out amongst staff. Studies have shown positive results by utilizing pharmacy students in their 3rd and 4th year, PGY1 residents, and paid interns working together.4 Other studies emphasize the successfulness of community pharmacists assisting with heart failure TOC encounters via the Centers of Medicare and Medicaid Services Part D Medication Therapy Management programs. These programs allow pharmacists to bill for counseling patients with multiple high-cost medications for various chronic disease states.6 Some health systems found success with clinical pharmacists working directly with the patients during discharge.1 Although there are many ways to set up a pharmacy-led TOC team, it is important to arrange a team best suited to the staffing abilities of different organizations. 

Heart failure remains one of the most prevalent disease states in the United States, and, in individuals over the age of 65 year, heart failure remains the most prevalent disease state that causes hospital admissions.7 Data predictions show that more than 8 million adults will be affected, and $69 billion will be spent by 2030 due to the overwhelming amount of hospitalizations.6 The benefits of providing pharmacist-led TOC can help improve these outcomes substantially, and this team can look different based on different preferences. Providing medication reconciliation to patients regarding their heart failure medications is one of the best ways to help improve overall quality of life and decrease the amount of money spent on heart failure readmission by catching discrepancies, titrating doses appropriately, and educating patients on proper use of their medications.7

Takeaways and Recommendations

  • Many patients transition to the home setting where both the patient and any caregivers need proper educational materials
  • Pharmacists provide valuable services in reducing 30-day readmission rates for heart failure patients through TOC-related counseling
  • Timely follow-up, either in-person or via phone, with a pharmacist is monumentally beneficial


  1. Benge C, Pouliot J, Muldowney JAS 3rd. Evaluation of a Clinical Pharmacist Specialist Transition of Care Pathway to Manage Heart Failure Readmissions During a Provider Shortage. J Pharm Pract. 2021 Jun 1;1-11.
  2. Centers for Medicare and Medicaid Services. Hospital Readmissions Reduction Program (HRRP), 2021. Available from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HRRP/Hospital-Readmission-Reduction-Program [6 August 2021].
  3. Cowie MR, Anker SD, Cleland JGF, Felker GM, Filippatos G, Jaarsma T, Jourdain P, Knight E, Massie B, Ponikowski P, López-Sendón J. Improving care for patients with acute heart failure: before, during and after hospitalization. ESC Heart Fail. 2014 Dec;1(2):110-145.
  4. Neu R, Leonard MA, Dehoorne ML, Scalia SJ, Kale-Pradhan PB, Giuliano CA. Impact of Pharmacist Involvement in Heart Failure Transition of Care. Ann Pharmacother. 2020 Mar;54(3):239-246.
  5. Schmaltz SP, Williams SC, Chassin MR, Loeb JM, Wachter RM. Hospital performance trends on national quality measures and the association with Joint Commission accreditation. J Hosp Med. 2011 Oct;6(8):454-61.
  6. Anderson SL, Marrs JC. A Review of the Role of the Pharmacist in Heart Failure Transition of Care. Adv Ther. 2018 Mar;35(3):311-323.
  7. Milfred-LaForest SK, Gee JA, Pugacz AM, et al. Heart Failure Transitions of Care: A Pharmacist-Led Post-Discharge Pilot Experience. Progress in Cardiovascular Diseases. 2017;60(2):249-258.

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