Improving convenience of access
These experts agree that convenient access to medications is a major factor supporting long-term medication adherence.
As Notaro says, “I see patients starting to take care of their medications around the area of convenience.” For these patients, concepts such as medication synchronization and compliance packaging are improving medication adherence. “If you say to a patient, ‘I can make it so that you get all of your medications at one time and then you don’t have to keep coming back to the pharmacy,’ that’s where I see patients starting to take care of their medications. Really, it’s a convenience factor.”
“As obvious as this may sound, most of the time this isn’t done,” Boehringer says. “Most of the time, patients get a new prescription for medication and need to refill it based on when the prescription first started. But maybe they got their prescriptions at all different times. Medication synchronization gets them filled all at the same time, and that helps with adherence—and gives the pharmacist an opportunity to educate at the same time on all those medications.”
Notaro agrees that strategies such as medication synchronization have benefits to care providers as well as patients. “The interesting thing about this convenience factor is there are a lot of clinical benefits to it. When I do the medication synchronization, I’m forced to do a medication reconciliation, I get to ask about drugs that look like they’re duplicates, etc. It stimulates a conversation about the medications the patient is taking,” he says.
Another strategy Boehringer sees as impactful is motivational interviewing. “The whole idea is to help patients commit to a change. It’s about asking the patient what they see as a pro or con of a drug so they make the decision to stick with it; it’s about getting that buy-in. It takes a little bit of time, which is going to be one of the challenges, but if you get the patient to buy in, with motivational interviewing they’re more likely to stick with it.”
No matter the strategy, Boehringer finds that community pharmacies are becoming an integral part of the journey to reduce hospital readmissions. “Community pharmacies are definitely reviewing a variety of solutions to empower patients with medication management and again encourage them to manage their own medication, and to provide care that is appropriate for the individual patient,” she says.
Ongoing support for improved medication management programs
Notaro adds that federal support is coming to improve health system access to these innovative, and effective, medication management programs.
“Medicare Part D on medication therapy management really stimulated the idea of doing consistent, ongoing medicine reviews,” Notaro says. “The requirement has been around since 2006—the Bush administration really prescribed how this should get done in its 2010 call letter, and then the Obama administration put that into law with the Affordable Care Act … Medicare Part D really institutionalized this idea of plan-based value medication reviews, and now it’s starting to osmose into the Medicaid environment.”
The Tennessee Senate and House, he notes as one example, are considering the adoption of legislation requiring all Medicaid managed care providers who participate in the state Medicaid program to incorporate a medication management program into their offering.
“As integrated healthcare environments start to assume risk for pharmacy budget, we’re starting to see uptake in the ACL marketplace,” Notaro says. “I think the industry says [medication management] is working enough that we need to explore it.”
Some of this exploration is coming from areas such as enhanced medication therapy management (MTM), a model from the CMS Innovation Center. The Part D Enhanced MTM model is intended to help standalone basic Part D plans “right-size” their MTM services by implementing innovative strategies that optimize medication use, improve care coordination, and strengthen healthcare system linkages. Launched in January 2017, the five-year program is being tested in five regions.
The Part D Enhanced MTM model is working to assess whether providing selected Medicare prescription drug plans with additional incentives and flexibility to implement innovative programs will better achieve the overall goals for MTM programs. Those goals include better compliance with medication protocols to ensure beneficiaries get the medications they need and use them properly; reductions in medication-related problems such as duplicative or harmful prescription drugs, or suboptimal treatments; increasing patients’ medication education; and improving communication among prescribers, pharmacists, caregivers, and patients.
“So people are saying how do we do it better, how do we optimize this thing?” Notaro says.
Incorporating caregivers into the medication management team
Of course, there’s one more ally to which hospitals can turn in their journey to improve patients’ medication management. A University of Pittsburgh Health Policy Institute analysis published in April found that systematically integrating informal caregivers into the discharge planning process for elderly patients reduces hospital readmissions by a quarter.
The study, published in the Journal of the American Geriatrics Society, is the first to quantify the post-discharge impact of caregiver integration into discharge planning on healthcare costs and resource utilization. Caregivers are typically family members of the discharged patient, but they can also be friends, partners, or neighbors, among others. A recent Congressional Budget Office analysis found that caregivers provide 80% of community-based long-term services and support for older adults.
The studies included 4,361 patients with an average age of 70 years. Integrating caregivers into discharge planning resulted in a 25% reduction in risk of the elderly patient being readmitted to the hospital within 90 days, and a 24% reduction in risk of being readmitted within 180 days, when compared with control groups where no such integration occurred.
“While integrating informal caregivers into the patient discharge process might require additional efforts to identify and educate a patient’s family member, it is likely to pay dividends through improved patient outcomes and helping providers avoid economic penalties for patient readmissions,” commented senior author A. Everette James, JD, MBA, director of Pitt’s Health Policy Institute and its Stern Center for Evidence-Based Policy, on the release of the study.
In other words, hospitals seeking to reduce readmissions through improved medication management can’t do it alone. Without some form of community partner during the transition of care, too many patients are likely to return to the hospital within a month or two after discharge.
Megan Headley is a contributing writer to Patient Safety & Quality Healthcare.