Reducing readmissions: The hospital–community connection
The Hospital Readmissions Reduction Program, a hallmark of the Affordable Care Act (ACA), is changing the earning mechanism of inpatient health care facilities nationwide. Organizations whose earnings once relied solely on services rendered now must prove their services are effective at keeping the patient out of the hospital after discharge.
Hospital problem, community solution
The readmission reduction program penalizes hospitals with above-average 30-day readmission rates of patients who fit certain criteria. Currently, penalties apply to readmissions of Medicare patients aged 65 years and older who are admitted for heart attack, heart failure, or pneumonia. In October, readmissions of patients who are admitted for elective hip or knee replacements or chronic obstructive pulmonary disease will also count toward penalties. Calculation of penalties is based on a number of variable factors. Penalties this year may total up to 2% of a facility’s Medicare inpatient claims payments. Penalties next year could reach 3%.
Community pharmacists can play an important role in helping hospitals reduce readmissions. An estimated two-thirds of adverse events post-discharge are medication related, and studies show that pharmacist interventions improve medication adherence, which reduces hospital admissions and emergency department visits. Hospitals, pharmacies, and payers around the country are leveraging community pharmacists to improve care as patients transition from hospital to home.
Communication is key
“One of the biggest needs in transitions of care is communicating [to the community pharmacy] that the patient is being discharged from the hospital,” said Jeff Freund, PharmD, a senior clinical instructor at University of Colorado’s Skaggs School of Pharmacy and Pharmaceutical Sciences.
Community pharmacists are frequently kept out of the loop. Throughout his 30 years as the owner of Abrams & Clark Pharmacy in Long Beach, CA, John Sykora, BSPharm, MBA, is often frustrated to learn that a patient has been in the hospital without his knowing it. “We weren’t getting information from hospitals about the patients they were discharging, and we had no way of knowing what therapy the patient was changed to,” Sykora said. “We’d run into difficulties later because patients just weren’t going onto the new therapy.”
Although the ACA now requires that hospitals give patients certain basic information and written instructions during discharge, the law does not ensure that the information gets any further than patients’ hands. “I thought it was great that there were now orders out there,” noted Sykora, “but the hospitals didn’t tell patients who to give the orders to. They weren’t passing [the orders] on to us, and they weren’t passing [them] on to their primary care physicians,” Sykora said.
Failure to alert community pharmacists that a patient has been discharged means excluding the most accessible community health care provider from transitional care. “We know from the literature that being in the hospital is not a good place and time to absorb new information [about medication therapy],” said Karen Pellegrin, PhD, MBA, who directs University of Hawaii’s Pharm2Pharm Care Transitions Program, a 3-year pilot program in its second year that is funded by a CMS Health Care Innovation Award. “No matter how good that education is on the inpatient side, it’s very difficult to translate it to the outpatient side,” Pellegrin added.
Pharm2Pharm establishes a partnership between hospital and community pharmacists that facilitates patient hand-off. Hospital pharmacists identify candidates based on a checklist of criteria for postdischarge medication therapy management (MTM) services in the community. In addition to educating patients about their medication while they are in the hospital, hospital pharmacists set up a postdischarge appointment for the patient at a participating community pharmacy of the patient’s choice.
“That hospital pharmacist is working with the patient, but it’s really just the beginning of the education process for the patient,” said Pellegrin, who is also Director of University of Hawaii College of Pharmacy’s Center for Rural Health Science.
Other care models call on payers to identify patients in need of transitional care. Ohio-based CareSource, the state’s largest Medicaid managed care plan, offers an MTM benefit to all beneficiaries. Sarah Kelling, PharmD, MPH, arranged for CareSource to refer all patients who were discharged in her rural area to the Kroger in Marion, OH, where she was a resident. This model, she noted, works well in areas where patients often travel far from home for care.
“The community had one hospital. If I had partnered with just that hospital, we wouldn’t have captured the patients who went to facilities in Columbus, for example,” said Kelling, Clinical Assistant Professor at the University of Michigan’s College of Pharmacy. “By working with the insurance company, any patient [from that community] who was insured through CareSource, was 18 or older, and was discharged from some type of health facility was referred to my pharmacy.”
Patients in the community
Partnerships among community pharmacies, payers, and inpatient care facilities streamline transitions of care, but community pharmacies can identify recently discharged patients in other ways as well. “We call our patients once a month to review drug therapy, and we always ask, ‘Have you been to the hospital? Have you been to your doctor?’ That will trigger us to follow up on whether there are changes,” said Sykora of his business model at Abrams & Clark Pharmacy.
In the care model that Colorado’s Freund studied, when pharmacists saw multiple prescriptions from a known hospital physician or on a hospital pad, the pharmacy technician called the hospital to ask for the discharge medication list as well.
More than med rec
Pharmacists have many responsibilities in transitions of care models that reach far beyond medication reconciliation. Community pharmacists ensure that patients have follow-up appointments with appropriate physicians. Pharmacists counsel patients about disease state management and recommended lifestyle changes. They also educate patients about conditions other than those for which they were hospitalized. “Seventy percent of 30-day hospital readmission rates are not the result of an exacerbation of the same disease state,” Kelling said. Those readmissions can incur penalties just the same, she added.
For example, when Kelling met with a patient who had been discharged from a physical rehabilitation center after a hip replacement, she thought he wouldn’t need her help. But the consultation became a comprehensive education session on diabetes management. “I could’ve said, ‘Oh, this person must be fairly healthy. I shouldn’t reach out to him.’ But there were reasons that his diabetes medicines didn’t show up in his medication history, and he actually needed a lot of support,” Kelling said.
High-tech not necessary
Electronic medical records, health information exchanges, and other prescription drug databases can facilitate care transitions programs. However, many successful programs are relatively low-tech. In Freund’s model, community pharmacies requested discharge orders via fax, input reconciliation forms into their systems, and performed a medication reconciliation to review with patients during a consultation.
Hawaii’s Pharm2Pharm program is also low-tech. “We launched this model with some fancy technology called ‘cell phones’ and ‘fax machines,’” Pellegrin said. The program is now in the process of integrating more technological support, such as use of the Hawaii Health Information Exchange.
Kelling in Ohio had access to some of her patients’ medical records, but not all of them. “It was much easier with the electronic medical records to gather the information that I needed to make appropriate recommendations and provide education to the patient, than when I was struggling to get something as basic as a medication list,” she said.
The financial incentive to improve care transitions lies within the hospitals, but there is not a standard method to reimburse community pharmacists for this type of service. CareSource is among the few payers that cover MTM services for beneficiaries. Pharm2Pharm pays pharmacists through a government grant. “We need payers to pay for this value-added service,” Pellegrin said.
Payers are not the only ones who need to understand the value of pharmacists’ services. Patients do, too, and it is pharmacists’ job to teach them. “I developed this program thinking, ‘If I can get ahold of a patient, they’re going to want to come in and talk to me. I’m providing a free service for them,’” Kelling said. “But people don’t necessarily see the value of something they’ve never heard of before.”
Ideally, all stakeholders in the community and the health care system should understand the importance of transitional care and have a hand in it. “Community physicians, nurses, or social workers could possibly identify patients at high risk for readmission,” Kelling said. “The more partnerships you have, and the more stakeholders involved, the better the program will be able to meet the needs of patients in your community.”