Impact of Pharmacist-Led Discharge Interventions in the Multi-Visit Patient Population
Background: Multi-visit patients (MVPs), defined as individuals with three or more hospital admissions within a 12-month period, represent a high-risk population with significant chronic disease burden and increased risk of early readmission. Frequent hospitalizations, particularly similar conditions, are associated with worse clinical outcomes and increased healthcare utilization. Pharmacist involvement during care transitions has been shown to improve medication management and patient outcomes; however, data evaluating the impact of pharmacist-led interventions in MVP populations remain limited. This study aimed to assess the impact of pharmacist-led post-discharge medication review in this high-risk population.
Methodology: This retrospective chart review included Medicare enrolled MVPs who were discharged from AdventHealth Celebration between September 15, 2025, and January 16, 2026. Patients were excluded if they were discharged to an inpatient rehabilitation unit (IPR), skilled nursing facility (SNF), hospice, left against medical advice, transferred to an outside hospital, expired during hospitalization, or patients with current malignancy treated with systemic therapy. Eligible patients were identified by a nurse educator and referred for a post-discharge medication review call conducted by a clinical pharmacist. All eligible patients received an attempted telephone outreach. The primary outcome was 30-day hospital readmission rate. Outcomes were compared between patients who successfully completed the post-discharge pharmacist call and those who were unable to be reached or declined participation. Secondary outcomes included the rate of identical (potentially preventable) 30-day readmissions, defined as readmissions for the same or clinically similar condition as the index admission. Secondary outcomes also included the number of medication discrepancies identified and resolved. Additional process measures included the incidence and type of patient counseling and education provided (e.g., medication-related, disease state, lifestyle, self-monitoring, and adherence counseling), as well as the number and type of pharmacist recommendations, including medication initiation, discontinuation, dose adjustment, and laboratory or immunization recommendations.
Results: A total of 40 MVPs were identified during the study period. Of these, 22 patients met inclusion criteria, leaving 18 patients eligible for inclusion who received an attempted post-discharge medication review call from a clinical pharmacist. Among the 18 eligible patients 12 (66.7%) successfully completed the pharmacist-led telephone encounter, while 6 (33.3%) were either unable to be reached or declined participation. The 30-day readmission rate was 50% (n=6) among patients who completed the call, compared to 33% (n=2) among those who did not complete the call. Among patients who completed the intervention, a total of 33 medication discrepancies were identified and resolved (mean 2.8 per patient). Additionally, over 50 patient counseling interventions were performed, with the majority categorized as medication-related or disease state-related education. A total of 33 pharmacist recommendations were made, most commonly involving medication dose adjustments. Other recommendations included medication initiation, discontinuation, and laboratory or immunizations.
Conclusion: Pharmacist-led post-discharge medication review in a high-risk multi-visit patient population identified a substantial number of medication discrepancies and generated clinically meaningful interventions, including medication optimization and patient education. Although no reduction in 30-day readmissions was observed, these findings highlight the potential role of pharmacists in improving care transitions and addressing medication-related problems in medically complex patients. Larger studies are needed to further evaluate the impact of these interventions on clinical outcomes in this population.
