Accountable Care in Transitions (ACTion): A Team-Based Approach to Reducing Hospital Utilization in a Patient-Centered Medical Home:

Background:There is limited data describing the role of the patient-centered medical home (PCMH) in successful transitions programs and more information is needed to determine the transition points where pharmacist involvement is most impactful.Methods:A family medicine center developed a multidisciplinary outpatient-based transitions program focused on reducing emergency department (ED) and hospital use in medically complex patients. Key team members were a medical provider, clinical pharmacist practitioner (CPP), and care manager. The objective was to evaluate the impact of the program by comparing utilization before and after the intervention and to identify patient and process characteristic predictors of 30-day rehospitalizations.Results:Of the 268 patients included, the mean time to follow-up appointment attended was 11.6 (11.8) days after discharge. The majority of patients (72%) saw their primary care provider at follow-up. Patients experiencing the multidisciplinary intervention had lower 30-day ...