"Gregory” is an 85-year-old patient in the Indiana, PA, area who has chronic obstructive pulmonary disease (COPD). He was in and out of the hospital multiple times because of his chronic condition until 2013, when he became part of an innovative model of care that brings together a small group of health professionals, including a pharmacist, who are dedicated to improving transitions of care and reducing readmissions.
Once enrolled in the Primary Care Resource Center (PCRC) model at Indiana Regional Medical Center in Indiana, PA, Gregory received personalized medication counseling from Laura Muchesko, PharmD, a PCRC pharmacist. “I got connected with Laura when I was in the hospital,” said Gregory. “We went over my whole medication list—and I’ve got a big list.”
After Gregory was discharged, Muchesko conducted follow-up phone calls and visited Gregory at home. “She spent an afternoon with me. She’s real easy to talk with, and she explained how all my medicines are supposed to work for me,” added Gregory. “Laura always takes the time to explain everything I want to know.”
Thanks to the efforts of Muchesko and the PCRC team at Indiana Regional Medical Center, Gregory has managed his COPD successfully at home, with only one admission to the hospital compared with four admissions the prior year.
“A big chunk of what I care about is being sure patients understand how to take their medications and have their medication questions answered,” said Muchesko. “I really do feel like I’m helping people every day.”
The PCRC concept grew out of the Pittsburgh Regional Health Initiative, which initially launched successful COPD readmission reduction pilot programs in two Pittsburgh hospitals, followed by a PCRC prototype in a community hospital in western Pennsylvania. Based on the success of these programs, in May 2012 the Pittsburgh Regional Health Initiative received a 3-year, $10.4 million award from the CMS Center for Medicare and Medicaid Innovation (CMMI) to create a series of six hospital-based PCRCs, each staffed by three nurse care managers, a pharmacist, and an administrative assistant.
The PCRCs focus on smooth care transitions for complex patients with heart failure (HF), acute myocardial infarction (AMI), and COPD to reduce readmissions and the overall cost of care and improve care quality. “Pharmacists are critical members of the team,” said Keith Kanel, MD, MHCM, FACP, Chief Medical Officer of the Pittsburgh Regional Health Initiative and Director of the multistate PCRC project. “Pharmacists are in charge of medication reconciliation and they spend time doing face-to-face personalized counseling in the hospital and at the patient’s home.”
Approximately 20% of Medicare beneficiaries are readmitted within 30 days of discharge from the hospital, and individuals with chronic conditions like HF, AMI, and COPD may see up to 15 physicians in 1 year. “When we asked primary care physicians about their patient care needs, they said we need more help with complex patients,” explained Kanel.
In addition to medication reconciliation and education, the PCRC provides many other services related to improving a patient’s overall care and lifestyle in order to reduce readmissions.
“The PCRC includes smoking cessation programs and nutrition services, among others. These were services that were already occurring in the hospital and we created a single place where patients can access them. It’s one-stop shopping,” said Kanel.
The Pittsburgh Regional Health Initiative began its work with care transitions in 2009. “We looked specifically at successfully managing patients with COPD, which is a big driver of readmissions in our region,” Kanel explained. “We initially had great success with the pilot programs, and then we began building on the concept to extend it to patients with HF and AMI.”
According to Kanel, the group, through the PCRC prototype, was able to lower readmissions by 47% within 6 months of beginning the program.
In the early days of the project, the PCRC team did not include a pharmacist. “We made sure patients were seen at the point of admission, that they were fully educated while in the hospital, and the families were activated to be supportive, but this was done by the nurses,” said Kanel.
Although the project was successful, it wasn’t until a pharmacist was added to the team in 2012 that everything came together.
“We had the pharmacist meet with the patient in the hospital, call the patient after discharge to make sure the patient acquired their medications and that the patient was doing well,” said Kanel. “We realized that this was incredibly efficient and incredibly cost effective.”
Based on the success achieved when a pharmacist was added to the team, the Pittsburgh Regional Health Initiative applied for and received a CMMI grant, and launched the PCRC concept in the following area hospitals:
Once a patient is admitted to the hospital with COPD, HF, or AMI, he or she is evaluated and contacted by a member of the PCRC team. “I meet the patient in the hospital and talk to them about their medications—do they have insurance coverage, are they aware of their medications, what their medications are like at home, what medication changes have happened. I touch base with all of that and provide medication education,” said Muchesko. “I also make sure the medication list at the hospital matches the home list, and that the list also matches the doctor’s office list. Everyone needs to be on the same page.”
Once a patient is discharged and settled in at home, Muchesko calls to reinforce the medication education and reviews any other changes or problems. “Often when a patients gets home they have more questions. They realize they’re not sure of the bottles they’re looking at. At that point, I address all that,” she said.
In many instances Muchesko helps patients overcome unanticipated barriers. “My job is so much more than talking just about medications,” said Muchesko. “I take care of the whole person.” For example, one patient was afraid to take her prescriptions to a pharmacy to get them filled because she was afraid of the copay. “I talked to the patient about it, and after our conversation the patient took the prescription in and got it filled,” said Muchesko.
Kanel and the team at Pittsburgh Regional Health Initiative have high hopes for the PCRC care model. The project’s goal is to reduce all-cause 30-day readmission rates among patients with HF, AMI, and COPD by 40%, with estimated savings to Medicare of approximately $41 million.
During the period of the CMMI grant, the Pittsburgh Regional Health Initiative’s program will train an estimated 450 health care workers and create an estimated 26 new jobs.
“It’s a wonderful thing to be able to help these patients and provide education and information,” said Muchesko. “It all has to tie together and be part of a care continuum. Without the pharmacists, there would be a piece missing.”