• Bruce A Warden, Jessica Pryor Freels, Jon P Furuno, and John Mackay.
• Bruce A. Warden, Pharm.D., BCPS, is Clinical Pharmacist; and Jessica Pryor Freels, Pharm.D., M.S., is Clinical Operations Manager, Oregon Health and Science University (OHSU), Portland. Jon P. Furuno, Ph.D., is Associate Professor, Department of Pharmacy Practice, Oregon State University/OHSU College of Pharmacy. John Mackay, Pharm.D., BCPS (AQ-Cardiology), is Advanced Heart Failure Clinical Pharmacist, OHSU.
• Am J Health Syst Pharm. 2014 Jan 15;71(2):134-9.

PurposeThe impact of a pharmacy-managed program for providing education and discharge instructions for patients with heart failure (HF) was evaluated.MethodsA before-and-after quasiexperimental design was used to quantify the effect of a pharmacist-managed HF medication education and discharge instruction program on the incidence of 30-day readmission rates and adherence to targeted Joint Commission core measures for HF (the provision of discharge instructions and the prescribing of an angiotensin-converting-enzyme inhibitor [ACEI]/angiotensin II receptor blocker [ARB] at discharge or documentation of the reason if therapy was not prescribed). Adult patients admitted to Oregon Health and Science University's cardiology unit with systolic HF exacerbation as their primary diagnosis between December 2010 and March 2011 were included. Throughout patients' hospitalization, the pharmacist collaborated with the multidisciplinary team to make treatment and monitoring recommendations; provided discharge medication reconciliation, discharge medication recommendations, and discharge instructions; answered patient-specific questions; and gave the patient a complete discharge medication list.ResultsThe study enrolled 35 patients and compared results against a historical control group of 115 patients. The frequency of discharge counseling increased significantly (p = 0.007), as did the rate of ACEI/ARB prescribing at discharge (p = 0.02). Both 30-day all-cause and HF-related readmissions were reduced compared with baseline (p = 0.02 and p = 0.11, respectively).ConclusionPharmacist involvement in medication reconciliation and discharge counseling for HF patients was associated with a significant increase in adherence with the Joint Commission's core measures, a significant reduction in 30-day all-cause readmissions, and a positive effect on patient satisfaction.

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