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An electronic personal health record (ePHR) is at the heart of a medication management program in Rhode Island that aims to help recently discharged hospital patients avoid a return to the hospital. Researchers from the University of Rhode Island College of Pharmacy implemented the program in 2011 in partnership with Healthcentric Advisors, the state’s Medicare Quality Improvement Organization (QIO); the state’s Division of Elderly Affairs; and local hospitals.
The Rhode Island Care Transitions Program targeted state residents with diabetes, respiratory illness, cardiovascular disease or related conditions. Patients joined the program at the invitation of the QIO or nurse case managers working within the state's Medicaid program. Some participants were recruited while receiving care at the local community hospital. A pharmacist implemented the program by:
According to a report about the intervention published by the Center for Aging and Technology in Oakland, CA:
Researchers identified several lessons they learned from the pharmacist-directed care transition program: