Impact of a combined pharmacist and social worker program to reduce hospital readmissions

BACKGROUND: The Patient Protection and Affordable Care Act (2010) directed the Centers for Medicare and Medicaid Services to implement a hospital readmissions reduction program that reduces payments to hospitals for excess readmissions that began in October 2012. As such, hospitals across the country have been trying to identify and implement successful strategies for reducing hospitalizations. OBJECTIVE: To evaluate the impact of a combined pharmacist and social worker program on reducing 30-day, all-cause readmission rates to the same hospital. METHODS: Our study design was a retrospective, cross-sectional study that included 100 inpatients discharged from a large academic medical center. Fifty patients were enrolled in the combined pharmacist and social worker program, and 50 received usual care; all were deemed high risk for readmission due to clinical or social factors. In the program group, a phar- macist performed a thorough medication history and review of discharge medications and, in some cases, communicated with the patient after discharge. The program group was also followed by a social worker team in the hospital and after discharge; as necessary, psychosocial interventions were performed. RESULTS: The 2 patient cohorts had similar demographic and clinical char- acteristics. Ten percent of patients enrolled in the combined pharmacist and social worker program were readmitted to the hospital for any reason within 30 days of discharge, compared with 30% of patients in the usual care group (P = 0.012). CONCLUSION: The combined pharmacist and social worker program dem- onstrated a significant reduction in 30-day, all-cause readmission rates to the same hospital.