Evaluation of a pharmacist-led telehealth transitions-of-care program: A multisite analysis of program impact on readmissions

PURPOSE: Hospital discharge poses risks of adverse outcomes for patients, especially those at high risk for readmission. While some evidence suggests that pharmacist-led transitions-of-care (TOC) programs may be effective in reducing readmission rates, evidence of long-term effectiveness is limited. The aim of this study was to evaluate the impact of a pharmacist-led telehealth TOC program on 30- and 90-day hospital readmission rates. METHODS: This retrospective study analyzed 116,251 adult patients discharged from a large health system in 2024. Of these, 2,253 patients participated in the TOC program, which included a meds-to-beds program, prior authorization support, medication reconciliation, and counseling by pharmacists within 2 to 3 days of discharge. Using propensity score matching, TOC and non-TOC groups were matched on age and LACE (length of stay, admission acuity, comorbidities, and emergency department use) score, designed to predict readmissions. Outcomes were compared using χ2 tests and logistic regression. RESULTS: After matching, with all LACE levels combined, the TOC group had significantly lower readmission rates than the non-TOC group for both time periods (30 days: 8.6% vs 11.8%; 90 days: 16.2% vs 20.0%; P < 0.01). The TOC group was associated with 30% (30 days) and 24% (90 days) lower odds of readmission. Differences in readmission were significant between the groups for patients with a high LACE score but not for those with low to medium LACE scores. CONCLUSION: The pharmacist-led telehealth TOC program significantly reduced hospital readmission rates. These findings support the implementation of pharmacist-led TOC programs and suggest the importance of risk stratification in targeting interventions.