“Having Care Navigator pharmacists dedicated to following up with patients as they transition to different settings has been very helpful,” Finder adds. “I think that more pharmacist discharge counseling on the inpatient side, bedside medication delivery, and identification/resolution of medications that may require prior authorization prior to discharge would all be very beneficial.”
Taking the first opportunity to reconcile medication
By focusing on medication management before discharge, hospitals are able to take the first step in preventing one of the most common causes of readmissions. Such was the finding when Robert Phillips, MD, PhD, FACC, executive vice president, chief medical officer, and chief quality officer at Houston Methodist, collaborated with researchers from other health centers to better understand the impact and costs of programs to reduce hospital readmissions, as well as the drivers of these readmissions. The TEXAS Project identified the most common readmission reduction tools, and it determined that medication management, with an emphasis on medication reconciliation, had a significant impact on hospital readmissions.
Finder describes the program: “We implemented an automated calling program at Houston Methodist Hospital, and between December 2016 and February 2017 we contacted a total of 6,782 patients. Of these, 3,703 (55%) patients completed the telephonic questionnaire and 1,037 (28%) triggered alerts. The drivers of the alerts were related to instructions (11%), medications (9%), follow-up care (8%), services (7%), health status (3%), and contact request (3%). There were 122 alerts related to patients not being able to fill prescriptions and 240 medication question alerts,” Finder says.
“Common targeted high-risk medications include new oral anticoagulants, antibiotics, and pain medications,” she continues. “Some of our findings include patients not being able to get oral anticoagulants filled after being diagnosed with pulmonary embolism; not being able to afford nebulized medication after being discharged with respiratory failure; not realizing that aspirin needs to be continued along with Plavix after a cardiac stent placement, etc. All those scenarios could easily result in a hospital readmission.”
The hospital’s Care Navigator pharmacists were able to resolve 90% of the medication-related alerts through patient education and collaboration with physicians, retail pharmacies, and insurance companies. This included addressing medication-therapy discrepancies and facilitating insurance prior authorization requests.
Finder notes that Houston Methodist’s Care Navigator department, which provides patient-centered care coordination, reports its findings to the hospital so that various stakeholders can be made aware of transition issues and improve their processes.
Collaboration with other care providers is vital in strengthening patients’ medication adherence. In fact, mounting evidence suggests medication adherence is strongest when the hospital reaches out to outpatient care providers in the community.
Boehringer points to a 2014 study in the American Journal of Health-System Pharmacists by H.S. Kirkham as evidence that pharmacist-led transition of care programs can have a significant impact on hospital readmissions.
The study followed the transition of care program run by two acute care hospitals; this program included bedside delivery of post-discharge medications and follow-up telephone calls two to three days after discharge. Over the two-year study period, the researchers found that patients who did not participate in the program had nearly twice the odds of readmission within 30 days, compared with the intervention group. For patients age 65 or older, those in the usual care group had a sixfold increase in the odds of a 30-day readmission relative to those in the intervention group, the authors concluded.
“Communicating with the outpatient providers—whether that’s the pharmacist at the hospital talking to the community pharmacist or the hospital communicating with the family or primary care provider—and ensuring that there will be adequate follow-up is a really big thing. In most cases the patient should be seen within 7–14 days,” Boehringer says.
While the support role of the family can’t be overlooked, the community pharmacist is increasingly being seen as a pivotal player in medication management.
In March, a study in the American Journal of Managed Care found that patients receiving post-discharge care from pharmacists had a 28% lower risk of readmission at 30 days and a 31.9% lower risk at 180 days, compared with usual care. The pharmacist interventions focused on patient education, resolving medication-related problems, and easing access to post-discharge appointments and medications.
But there are challenges facing broader implementation of pharmacist-led programs. “Obviously one of them is the time needed by the community pharmacist to provide some of these extra activities,” Boehringer says. “Another big challenge is that the number of medications people are on is growing—so the potential for issues is increasing. Our elderly population is increasing too, and those tend to be the people on more medications. When you couple this greater need with the time issue, it’s a challenge.”
One of the potential solutions may be pharmacist provider status. “The idea is that if pharmacists were to get provider status, they would be able to be reimbursed by Medicare, and being reimbursed would give them more time to do some of these activities,” Boehringer says.
Finder notes that hospital pharmacy and retail integration through electronic medical records is another solution that can help the retail pharmacy better do its job by providing access to medication changes and patient needs. “Script Sync, which is the ability to align medication fills, makes it easier for patients to stay on their therapies—receiving consolidated delivery through the mail and in 30-day multi-dose packs so patients can easily remember,” Finder says.