Embedding Clinical Pharmacy in Transitional Care: A Telehealth Comprehensive Medication Management Intervention for Postdischarge Glycemic Optimization.

Abstract

Background: Hospital discharge is a high-risk period for patients with diabetes. Pharmacist-led comprehensive medication management (CMM) reduces hemoglobin A1c (HbA1c) in ambulatory settings, but structured telehealth CMM embedded within hospital-based transitional care platforms is rarely described. This article reports the implementation, fidelity, and observed outcomes of a telehealth CMM program for patients discharged with poorly controlled diabetes from a nonacademic hospital.

Methods: Using the Institute for Healthcare Improvement Model for Improvement, eight Plan-Do-Study-Act (PDSA) cycles (July 2024-July 2025) refined referral, enrollment, documentation, and follow-up workflows. Adults discharged from internal medicine with HbA1c > 8% and a hospital-affiliated provider were offered pharmacist telehealth visits at discharge, 30, and 60 days via a nurse-led warm handoff, at no cost through an in-kind partnership. Fidelity was tracked with run charts; outcomes were evaluated descriptively, with adjusted analyses in the supplement.

Results: Of 361 eligible patients, 209 were approached; 113 enrolled (54.1% of those approached). Non-enrollment reflected out-of-network providers (n = 152) or unreachability (n = 77). Visit attendance declined from 87% (30 days) to 66% (60 days); a median of 69% of routed notes received a provider response. Pharmacists generated 185 approved recommendations (58.4% diabetes-related). Among patients with follow-up values, mean HbA1c declined from 10.8% to 7.7% (enrolled, n = 81) and from 10.3% to 8.8% (not enrolled, n = 113; p < 0.001 at follow-up), while acute care utilization was unchanged. Enrollment and outcome gaps were observed for Black patients and Medicare enrollees.

Conclusion: Embedding telehealth CMM within existing transitional care infrastructure was feasible without new inpatient staffing. Key lessons include the value of warm handoffs, the difficulty of reaching the highest-risk patients, and the need for equity-informed outreach.