ArticleJournal of the American Pharmacists Association : JAPhA
Impact of an Area Agency on Aging pharmacist-led Community Care Transition Initiative.
Article in Journal of the American Pharmacists Association : JAPhA. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 2 papers.
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Who cites it
2 citing papers in PubMed, 3 citations in OpenAlex.
- Interprofessional collaboration between pharmacists and community health workers: a scoping review.International journal for equity in health · 2025Article
- Connecting the disconnected: Leveraging an in-home team member for video visits for older adults.Journal of the American Geriatrics Society · 2024Article
Corrections and comments
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Authors and funding
7 authors.
Funding
Abstract
backgroundRural older adults are at risk of readmissions and medication-related problems after hospital discharge.
objectivesThis study aimed to compare 30-day hospital readmissions between participants and nonparticipants and describe medication therapy problems (MTPs) and barriers to care, self-management, and social needs among participants. PRACTICE DESCRIPTION: The Michigan Region VII Area Agency on Aging (AAA) Community Care Transition Initiative (CCTI) for rural older adults after hospitalization. PRACTICE INNOVATION: Eligible AAA CCTI participants were identified by an AAA community health worker (CHW) trained as a pharmacy technician. Eligibility criteria were Medicare insurance; diagnoses at risk of readmission; length of stay, acuity of admission, comorbidities, and emergency department visits score more than 4; and discharge to home from January 2018 to December 2019. The AAA CCTI included a CHW home visit, telehealth pharmacist comprehensive medication review (CMR), and follow-up for up to 1 year. EVALUATION
methodsA retrospective cohort study examined the primary outcomes of 30-day hospital readmissions and MTPs, categorized by the Pharmacy Quality Alliance MTP Framework. Primary care provider (PCP) visit completion, barriers to self-management, health, and social needs were collected. Descriptive statistics, Mann-Whitney U, and chi-square analyses were used.
resultsOf 825 eligible discharges, 477 (57.8%) enrolled in the AAA CCTI; differences in 30-day readmissions between participants and nonparticipants were not statistically significant (11.5% vs. 16.1%, P = 0.07). More than one-third of participants (34.6%) completed their PCP visit within 7 days. MTPs were identified in 76.1% of the pharmacist visits (mean MTP 2.1 [SD 1.4]). Adherence (38.2%) and safety-related (32.0%) MTPs were common. Physical health and financial issues were barriers to self-management.
conclusionAAA CCTI participants did not have lower hospital readmission rates. The AAA CCTI identified and addressed barriers to self-management and MTPs in participants after the care transition home. Community-based, patient-centered strategies to improve medication use and meet rural adults' health and social needs after care transitions are warranted.
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