Community-based VTE Care Transitions Coordinated through a Senior Services Organization

Medication-related problems occur routinely during transitions of care, increasing the risk for adverse drug effects, therapeutic failures, and early utilization of healthcare services postdischarge. This is particularly true for medication-intensive conditions, such as venous thromboembolism (VTE). To reduce medication-related problems and the associated negative consequences, we will integrate a clinical pharmacist into an existing community-based care transitions program. Senior Services Plus Healthy Connections program utilizes transition coaches to screen seniors discharged from four community hospitals located in southwestern Illinois. The coaches provide home visits post-discharge to empower patients and caregivers regarding: follow-up appointments, medication management, health safety plans, transportation, and linkage to community resources.

Improving medication management has been identified as a quality initiative for the program, since medication-related problems are routinely encountered during the post-discharge home visits. We will conduct a prospective study including patients ≥ 60 years of age discharged with a diagnosis of VTE. Patients from two participating hospitals will serve as control subjects (one hospital no visit; one hospital transition coach only visit) and patients discharged from the remaining two hospitals will serve as intervention subjects (transition coach plus pharmacist visit). Targeted enrollment will be 120 patients per group and outcomes will be evaluated comparing: the number of and types of medication-related problems identified and resolved; VTE outcomes including recurrence and bleeding complication rates; and all-cause hospital readmission rates at 14, 30, and 60 days. The overall goal of the project is to improve the safety and effectiveness of medication use during care transitions from hospital to home for older adults treated for venous
thromboembolism (VTE).