title: Reducing unnecessary hospital readmissions: the pharmacist's role in care transitions.
abstract: OBJECTIVE
  Nearly one in five Medicare patients is readmitted to a hospital within 30 days of discharge. Most of these admissions are preventable, coming at a cost both to the patient's health and function and resulting in unnecessary health expenditures. With nearly two-thirds of postdischarge adverse events attributed to medications, pharmacists are uniquely suited to implement a homebased care transitions program with the goal of reducing unnecessary 30-day readmissions.
  
  
  METHODS
  Our model of care, which has been implemented by Medicare Advantage plans in Massachusetts and California, focuses on the transition from the acute and subacute setting to home.
  
  
  METHODS
  Within the first few days following discharge from acute or subacute facilities, the pharmacist visits patients in their homes.
  
  
  METHODS
  In collaboration with other health care providers, the pharmacist reconciles and optimizes medications from the multiple settings of care. In addition, he or she provides care management and ongoing support for 30 days postdischarge.
  
  
  METHODS
  The pharmacists' involvement in an interdisciplinary home-based transitions of care program provides patients with medication and care-management interventions that reduce 30-day readmission rates.
  
  
  RESULTS
  Over the past two years, Dovetail Health has demonstrated up to 30% reductions in network readmission rates for our health plan and provider group partners.
  
  
  CONCLUSIONS
  The novel role of the pharmacist in managing patient transitions of care from one site to another not only reduces unnecessary health care utilization and cost, but more importantly benefits the patient, who remains healthy at home following a hospitalization.
authors.affiliation: Dovetail Health, Needham, Massachusetts 02494, USA.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Novak
authors.forename: Sylvia
authors.initials: S
authors.lastname: Hastanan
authors.forename: Moje
authors.initials: M
authors.lastname: Moradi
authors.forename: Della F
authors.initials: DF
authors.lastname: Terry
mesh_terms: D002140:California; D003266:Continuity of Patient Care / Q000458:organization & administration*; D006699:Home Care Services / Q000458:organization & administration*; D006801:Humans; D008404:Massachusetts; D006278:Medicare; D017146:Models, Organizational; D010348:Patient Care Team / Q000458:organization & administration; D010359:Patient Readmission / Q000706:statistics & numerical data*; D010593:Pharmaceutical Services / Q000458:organization & administration; D010595:Pharmacists / Q000458:organization & administration*; D024382:Professional Role; D014481:United States