Learning by Definition
By John Barickman
Pay-for-performance initiatives have put hospital readmissions front-and-center in the national healthcare discussion. Now in its second year, for example, the Centers for Medicare and Medicaid Services’ Hospital Readmissions Reduction Program (HRRP) continues to evolve, increasing the financial risk for healthcare organizations with high readmissions rates by calculating their excess readmissions rate as compared to the national average. This determines the penalty to their readmissions payment adjustment, which can be as much as a two percent reimbursement reduction during the 2014 fiscal year. In 2015, this is scheduled to increase to a maximum of three percent.
With research conducted over the past decade revealing that nearly 20 percent of Medicare patients traditionally have been re-hospitalized within 30 days of discharge, these penalties represent a significant reimbursement hazard, especially for hospitals with high Medicare populations (Forster et al., 2003). Consider in 2013, Medicare levied $227 million in fines against 2,225 hospitals through HRRP—a noteworthy decrease from the $280 million against 3,400 hospitals the prior year, but still high enough to keep the reduction of readmissions high on the list of priorities for hospitals and health systems.
In fact, a number of movements are underway to minimize the potential for adverse post-discharge events, including the use of care managers who follow-up with patients and collaborate with other providers along the continuum of care. While strategically sound, these initiatives nevertheless overlook the fact that many adverse post-discharge events are medication-related and often could be avoided if pharmacists played a more direct and active role in patient care.
Going forward, a more collaborative approach to care that engages pharmacists in a top-of-license manner in patient education, medication reconciliation, and care transitions will be essential for moving the readmission curve in the right direction. As this model becomes more common, however, hospitals will have to identify tactics to better leverage pharmacy resources. More streamlined workflows will be required to free up staff time in order to better support efforts to lower admission rates.
Strategies for Medication Reconciliation and Care Transitions
An October 2012 study published in the Joint Commission Journal on Quality and Patient Safety revealed that unintended medication discrepancies occur in nearly one-third of patients, both at the time of admission and during transfer from one unit of a hospital to another (Gardella et al., 2012). Additionally, a 2012 study from the Annals of Internal Medicine found that 14 percent of these discrepancies occur during discharge (Kripalani et al., 2012).
With these kinds of statistics coming to light, hospitals are beginning to acknowledge the reality that transitions from one healthcare setting to another can substantially increase the potential for adverse events due to unintentional changes in patient medications. Therefore, medication reconciliation and effective care transitions that minimize errors have been identified across the industry as a critical focal point for reducing readmissions.
Handing the responsibility for appropriate medication reconciliation to pharmacists makes sense. Equipped with the knowledge needed to make informed decisions about the proper use of medications, pharmacy expertise should be leveraged for review of a patient’s complete medication regimen at admission, transfer, and discharge. An informed comparison can then be made when considering medications for any new setting.
The most effective medication reconciliation strategies include collaboration across the continuum of care—both inside and outside the walls of a healthcare facility. Aligning with industry movements toward accountable care models, pharmacists are best positioned to support readmission reduction efforts when they can establish partnerships with retail pharmacy groups and other caregivers to minimize the potential for error and ensure patients comply with care plans.
For example, a pharmacist will typically need to meet with a patient, review medications, and talk to other clinicians as part of a medication reconciliation process. In all likelihood, contact with an outside pharmacy will be required to get an accurate drug history. Post-discharge strategies should then include following up with patients several days later to confirm medications were obtained and are being taken correctly.
This collaborative approach to medication reconciliation generally works best in health systems that own or partner with specific retail pharmacies. The same is true when collaborating with other caregivers along the continuum, such as home health agencies. Although the process of improving inpatient and outpatient pharmacy operations can be more challenging when disparate organizations are involved, it can be done. In fact, establishing these partnerships and relationships will be critical for successfully reducing readmissions going forward.
Pharmacy’s Role in Patient Education
In today’s climate of lean budgets and limited staff resources, patient education can get lost in the myriad duties performed by nurses and other clinicians in hospitals. When faced with time constraints and the critical choice between completing patient education and performing other high-priority duties, providing patient education may consist of little more than handing the patient a pamphlet or turning on an educational video.
When pharmacy staff time can be leveraged to take ownership of patient education, the potential for reducing adverse drug events—one of the primary catalysts for readmissions—increases exponentially. Consider that nearly half of all U.S. adults (90 million) have impaired ability to understand health information, according to the Institute of Medicine (2004). As a result, a wide knowledge gap exists between providers and patients when it comes to medical terminology and the practical importance of any medication information presented. Pharmacy staff members have the potential to fill this gap if empowered to take on patient education efforts.
The best model entails putting medications into the hands of patients and educating them on appropriate medication use through one-on-one dialogue with pharmacy staff before they are discharged from hospital. Once again, achieving success with such a model requires cooperation among hospital staff, outpatient pharmacies, and other providers.
Forward-Looking Best Practices
While solid strategies focused on reducing readmissions across the board should be the long-term goal of any hospital, it is wise to kick-start efforts on a smaller, more manageable scale. Currently the HRRP program is built around three diagnosis-related groups (DRGs) including heart attack, heart failure, and pneumonia, so these conditions offer a good place to start. A hospital’s limited resources can be targeted at these areas as efficiently as possible.
However, even on a smaller scale, if pharmacists spend the bulk of their time on medication dispensing, inventory management, and other operational duties, adequate resources will not be available to perform more top-of-license responsibilities such as patient education and medication reconciliation. Therefore, having the right technology and processes in place will play a key role in any effort to redefine pharmacy workflows so pharmacists can lead these efforts.
Hospitals will need an effective infrastructure strategy that leverages pharmacy automation—such as barcode platforms and other inventory and operation management tools, for example—to streamline processes for a more efficient, accurate and safe approach to medication management. When pharmacy technicians can be utilized to provide support for technological processes, and pharmacists can be deployed for more decentralized patient care initiatives, the end result is better positioning for the value-based, performance-driven healthcare landscape.
More effective strategies to address medication reconciliation and patient education are no longer just items on hospital wish lists. They have become necessities for hospitals focused on reducing the potential for significant financial fallout associated with readmission rates. In light of the impact that adverse medication events play in readmissions, it only makes sense to conclude that the ability to better leverage pharmacy resources to enhance medication reconciliation and education can result in improved patient safety and higher quality care.
John Barickman is the senior executive pharmacist consultant at Aesynt. He may be contacted at John.Barickman@aesynt.com.
Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K., & Bates, D. W. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine, 138, 161–167.
Gardella, J. E., Cardwell, R. B., & Nnadi, M. (2012, October). Improving medication safety with accurate preadmission medication lists and postdischarge education. Joint Commission Journal on Quality and Patient Safety, 38, 452–458.
Institute of Medicine. (2004, April 1). Health literacy: A prescription to end confusion. Retrieved from http://www.iom.edu/Reports/2004/Health-Literacy-A-Prescription-to-End-Confusion.aspx
Kripalani, S., Roumie, C. L., Dalal, A. K., et al. (2012, July 3). Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: A randomized trial. Annals of Internal Medicine, 157(1), 1-10. Retrieved from http://annals.org/article.aspx?articleid=1206684