Pharmacy-led Transitions of Care Intervention to Address System-Level Barriers and Improve Medication Adherence in Socioeconomically Disadvantaged Populations

What this Trial Is About

Researchers are evaluating a pharmacy-led care transitions intervention designed to improve medication adherence among socioeconomically disadvantaged adults with multiple chronic conditions (MCC) after hospital discharge. This trial focuses on patients who are Medicaid recipients or uninsured, facing barriers such as financial challenges, transportation difficulties, and system-level obstacles. The study aims to address these issues through an innovative approach to reduce readmissions, healthcare costs, and mortality. The intervention includes providing essential chronic disease medications with zero copay, delivering medications first at the bedside and then to the patient's home, and offering care coordination by certified pharmacy technicians and health coaches. These coordinators assist with medication access, medication reconciliation, and ensure rapid and ongoing primary care follow-up after discharge. The intervention lasts for one year and is compared to usual care, which includes standard medication reconciliation and medication therapy management services where applicable. Participants will be followed for 12 months with assessments at 3, 6, 9, and 12 months to measure medication adherence, health care use including primary care follow-up, readmissions, hospitalizations, emergency visits, and costs. Qualitative interviews will explore patient experiences with the care transitions. Financial incentives are provided for completing follow-up surveys. The study's findings aim to inform healthcare systems and policymakers about effective ways to support medication adherence in vulnerable populations.

Pharmacy-led Transitions of Care Intervention to Improve Medication Adherence