テレフォンフォローアップを用いた薬・薬連携が心不全患者の経過に寄与した一例

抄録

Heart failure is associated with a high risk of recurrence, and preventing rehospitalization through improved medication adherence remains a major clinical challenge. We describe a case in which collaboration between hospital and community pharmacists, supported by structured telephone follow-up (TF), successfully prevented rehospitalization in a patient with heart failure. A man in his 50s was admitted for decompensated heart failure and responded well to guideline-directed therapy. However, he self-discharged prematurely due to worsening depression. After discharge, his adherence progressively declined, resulting in readmission within 3 months. At the second discharge, the medications were repackaged into unit doses, and administration responsibility was assigned to family members. The hospital pharmacist then requested TF from the community pharmacy with informed consent from the patient and his family. TF was conducted 1 week before each scheduled outpatient visit, and tracing reports (TRs) were submitted to the hospital pharmacist, who documented them in the medical record and relayed the information to the attending physician. This proactive flow of information enabled timely medical intervention, reinforced adherence, and prevented further symptom exacerbation. The patient has since remained stable without rehospitalization. This case illustrates the value of pharmacist-led collaboration across hospital and community settings, demonstrating how TF can serve not only as a motivational tool for patients but also as a practical mechanism for optimizing adherence and continuity of care. Such an approach may be particularly beneficial for younger patients who are not eligible for nursing care services and suggests that TF is a promising strategy for managing chronic heart failure.