Care transitions are a critical time for managing medications. Socioeconomically
disadvantaged populations with multiple chronic conditions (MCC) and polypharmacy have
high rates of medication discrepancies and nonadherence to essential chronic disease
medications following hospitalization. Medication nonadherence after hospital discharge
is significantly associated with increases in readmissions, costs, and mortality among
patients with MCC. Barriers to medication adherence for low-income patients are
particularly acute during care transitions from the hospital to the community setting,
where patients experience difficulties accessing and affording essential medications.
Studies including our own, have shown that major patient-reported barriers to essential
medication use after hospital discharge among low-income, primarily African American
individuals are related to social determinants of health (SDOH) and include: 1) financial
barriers (i.e., inability to afford medications), 2) transportation barriers (i.e.,
inability to access prescribed medications or needed follow-up care), and 3) system-level
barriers (i.e., lack of availability of discharge medications and care coordination
services to ensure rapid primary care follow-up).
Although medication therapy management (MTM) and medication reconciliation services are
important during care transitions, these services have not proven effective in improving
essential medication use and adherence after hospital discharge, highlighting a critical
need for innovative interventions that address the major barriers to adherence following
hospitalization. The PI Dr. Surbhi's pilot research has demonstrated the feasibility and
potential to improve medication adherence among adult Medicaid and uninsured inpatients
by directly addressing these barriers through full medication subsidy and bedside and
subsequent home delivery of medications. Additionally, our previous research demonstrates
that care coordination services provided by pharmacy technicians trained as coaches
effectively increases rapid primary care follow-up after hospital discharge and has
potential to help improve medication adherence. However, the effectiveness of
interventions that directly address affordability, accessibility, and availability to
improve post-discharge medication adherence in vulnerable populations is still unknown.
The Medication Affordability, Accessibility, and Availability in Care Transitions (Med
AAAction) Study will examine the effectiveness of a pharmacy-led care transitions
intervention versus usual care through a pragmatic randomized controlled trial of 388
Medicaid and uninsured hospital inpatients with MCC from three large non-profit
healthcare systems serving a disproportionate share of low-income patients in Tennessee.
The Med AAAction intervention will consist of the following components: 1) medications
with zero copay, 2) bedside delivery and subsequent home delivery of medications, and 3)
care coordination provided by certified pharmacy technicians/health coaches to assist
with medication access, medication reconciliation, and rapid and ongoing primary care
follow-up after hospital discharge. Furthermore, to understand patient experience with
the care received during and after care transitions, we will obtain qualitative data
through interviews with patients enrolled in the study. This study has a long-term goal
to demonstrate the effectiveness of a care transitions adherence intervention model for
vulnerable populations that can be readily adopted and sustained by health care delivery
systems across the US. The specific aims are as follows:
Aim 1: To test the effectiveness of the intervention on essential chronic disease
medication adherence (primary outcome) assessed by pill counts and a patient-reported
adherence scale. Hypothesis: Intervention group participants will have higher mean
adherence at 12 months compared with those randomized to the usual care.
Aim 2: To test the effectiveness of the intervention on following secondary outcomes:
Aim 2a. Health care utilization outcomes including: 1) primary care follow-up within 14
days of hospital discharge, 2) 30-day readmissions, 3) overall and preventable
hospitalizations at one year, and 4) overall and preventable emergency department (ED)
visits at one year using Tennessee Medicaid claims data and electronic medical records.
Hypothesis: Intervention group participants will be more likely to have rapid primary
care follow-up, less likely to have 30-day readmissions, and will have lower incidence of
hospitalizations and ED visits over a one-year period compared with those randomized to
usual care.
Aim 2b: Net cost savings associated with avoidable hospitalization and ED visits.
Hypothesis: The intervention group will incur lower costs compared to usual care.
Aim 3: To understand study participants' experience with the intervention received during
and after care transitions using qualitative key informant interviews.
Impact: By examining the effects of the intervention on medication adherence, health care
utilization, costs, and patient experience, the study will provide valuable results to
help health systems, payers, and policymakers achieve the Triple Aim - improving health
outcomes and patient experience and reducing costs, among socioeconomically disadvantaged
populations.
