Community pharmacist heads off hospital readmissions

Access to primary care and MTM can help keep patients out of the hospital

When Medicare began penalizing hospitals with excessive 30-day readmission rates in 2012, nearly one in five older adults was readmitted to the hospital within a month of discharge. Derek Singrey, PharmD, learned that Ohio was among the states with the highest readmission rates.

Singrey, who was then a student pharmacist at Ohio State University and now practices pharmacy full-time at Kroger, knew that access to primary care and medication therapy management (MTM) could help keep patients out of the hospital. Indeed, numerous studies show that medication problems are a major contributor to hospital readmissions. Singrey recognized that community pharmacists were in a unique position to identify patients at highest risk for chronic hospitalization and intercept them before readmission.

“From the community setting we can see the patient’s history. We can see all the different doctors they’ve gone to, what hospitals they’ve gone to, and we can pool that data and help them make better decisions in the future,” Singrey said, “rather than just going to hospitals for conditions that could have easily been helped in the outpatient setting.”

So Singrey and his classmate Andrew Burns designed a program for helping these patients. When a patient dropped off a hospital prescription for a medication for a chronic disease, Singrey and Burns would investigate to see if it was a new prescription and if the patient had a primary care provider. 

“We figured that by having better care in the physician office setting and in the pharmacy setting, we could deter those people from going to the hospital again and again,” Singrey said.

After Singrey and Burns identified patients with new diagnoses and no primary care, the pharmacist would counsel them, offer medication reconciliation, and refer them to primary care. The trick, however, was finding the time to counsel the patients. Because pharmacists have no way to bill health insurance for these preventive services, they had to squeeze these consults into short breaks in their drug-dispensing activities.

Like other pharmacists profiled in this series, the pharmacists at Kroger can’t always bill for these services because they do not have provider status. Provider status allows health care providers—including nurse practitioners, physician assistants, speech pathologists, and physical therapists—to bill health insurance companies for the services they provide. Community pharmacists, though they regularly provide preventive services like those in Singrey’s program, are left off the provider list in federal law.

During the experimental program, Singrey recalls a man who came in to pick up a heart medication for his wife, who had recently had a heart attack. She had returned to the hospital several times in the last few months and was discharged with a new prescription every time. When her husband came to Kroger, the woman was taking several drugs in the same class.

“This was a new diagnosis, and he didn’t know what to do or where to go for help. He was very appreciative that the pharmacist sat down with them,” Singrey said. “We gave him handouts, reconciled all the medications, and referred him to local clinics that he could take his wife to for long-term care.”

On a routine follow-up call a week later, Singrey learned that the man had sought primary care for his wife. While Singrey has no doubt that interventions like this keep readmission-prone patients out of the hospital, he worries that community pharmacies like Kroger have no way to sustain such interventions.

“The only income we can bank on from these interventions is hoping the patients will come back since we have a closer relationship with them. But nothing is guaranteed.”

While Kroger doesn’t earn any money from this intervention, interventions like this can save the health care system billions. An article in Annals of Internal Medicine in 2012 estimated that medication nonadherence costs the health care system $100 to $289 billion a year.

“It would be a sustainable service if there were some kind of money coming in from it,” said Singrey. “We’re mediators. It’s our duty to make sure that people have good outcomes from their medication. We’re responsible for monitoring drug interactions and side effects. I don’t understand how that’s not considered a health care provider when we provide all these services on a day-to-day basis throughout the country.”