2026 Southeastern Residency Conference

Background: An estimated 12% of the United States population is living with diabetes. This specific patient population is at an increased risk of hospital admission with longer lengths of stay and higher rates of readmission. Patients with diabetes are often lost to follow-up due to lack of disease education, access to medication, or access to care. At Cone Health, ambulatory pharmacists are embedded within primacy care clinics and provide disease state management and have been able to contribute to improve disease state related quality metrics. Inpatient diabetes coordinators identified embedded pharmacists to assist in transitions of care outreach to high-risk patients with diabetes upon hospital discharge.  The purpose of this study was to evaluate the impact of ambulatory pharmacist transitions of care outreach on diabetes control in patients recently admitted to the hospital.

Methods: This was a single-center, multi-site, IRB-reviewed and determined exempt, retrospective cohort, pre-post matched analysis that included patients with uncontrolled type 2 diabetes who were referred to an ambulatory care pharmacist during hospital admission between February 2025 and December 2025 for transitions of care outreach.  Ambulatory care pharmacists were encouraged to outreach patients upon discharge to address immediate medication access concerns in an effort to prevent readmissions and ensure adequate follow-up. Patients were included in the final analysis if there was documented pharmacist engagement and were affiliated with a Cone Health primary care clinic. The primary outcome was percent of patients meeting A1c <8% from baseline to follow-up which was assessed utilizing a McNemar’s Chi-square test. Secondary outcomes include 30-day all-cause unplanned readmissions, frequency of pharmacist engagement, and pharmacist-documented medication therapy problems and interventions.

Results: There were 139 patients referred to ambulatory pharmacy services for transitions of care outreach. A total of 103 patients were excluded due to study criteria. Of the patients referred, a total of 36 patients were included in primary statistical analysis. The mean age was 49.7 years, 13 (36.1%) patients were female, and 16 (44.4%) patients identified as Black or African American. A total of 32 (88.8%) of patients had type 2 diabetes with an average A1C of 11.7%.  At baseline, 1 patient (2.7%) had an A1C <8%. After pharmacist outreach and PCP follow‑up, 17 patients (44.4%) achieved an A1C <8% (difference 41.6%, 95% CI 25.6 – 57.8, p < 0.0001). The average time between baseline and follow-up A1C measurements was four months. During initial pharmacist outreach, medication therapy problems were identified with adherence (33.3%) being a top concern for patients, frequently driven by medication affordability and medication access barriers. Pharmacists were able to assist patients proactively through enrollment in patient assistance programs, switching to cost effective medications, completing prior authorizations, or referring patients to health system free pharmacies when appropriate. Patients continued to engage with ambulatory pharmacists on average of three times throughout the study duration. Continuous engagement further improved disease state management, medication access, and glycemic control.

Conclusions: Embedded pharmacist transitions of care outreach were associated with improvements on uncontrolled diabetes outcomes upon hospital discharge. More importantly, pharmacists were able to fill in the gap in the transitions of care process for patients with uncontrolled diabetes through providing access of care, medication accessibility, and reinforcing chronic disease state education. In addition to glycemic improvement, 30-day all cause unplanned readmissions rates were low. Patients were able to achieve A1C <8% from baseline to follow-up and a low 30-day all cause unplanned readmission rate was seen.

Presentation objective: Recognize key interventions an ambulatory care pharmacist can provide to support patients with uncontrolled diabetes during transitions of care.

Self-assessment question: Which of the following interventions was most commonly identified and addressed by pharmacists during transitions of care outreach?