Targeting transitions: Pharmacists critical to reducing readmissions

Pharmacists can take the lead in reducing hospital readmissions

Reducing avoidable rehospitalizations is on the radar of every hospital and health system in the country. Under the Affordable Care Act, Medicare has begun to financially penalize hospitals on 30-day readmission rates for certain conditions such as acute myocardial infarction, heart failure, and pneumonia. The idea is to encourage hospitals to reduce readmissions, which correlates to an increase in the quality of care. This new chapter in health care provides many opportunities for pharmacists to take the lead in readmission reduction programs both within the hospital and during transitions of care.

“Now is the best time ever for pharmacists to take the lead for what we do,” said Melinda Joyce, PharmD, FAPhA, FACHE, Vice President of Corporate Support Services at Commonwealth Health Corporation in Bowling Green, KY, during a session at the 2013 APhA Annual Meeting & Exposition in Los Angeles. Comprehensive medication reviews, patient and caregiver education, medication therapy management, and pre- and postdischarge counseling by pharmacists can reduce readmission rates for patients, she noted.

Why readmissions occur

A key factor in preventing readmissions is to figure out why they occur in the first place. According to Joyce, who is also Editor of Pharmacy Today’s Health-System Edition, patients are readmitted to the hospital for a number of reasons such as receiving no follow-up care, not understanding discharge instructions, problems with medications, lack of timely follow-up appointments, unmet postdischarge needs, or poor communication, especially with the primary care provider. Pharmacists are perfectly positioned to affect each of these factors, noted Joyce.

One of the most effective things pharmacists can do to improve hospital readmissions is to standardize the discharge process. When patients are being discharged, “all they hear is ‘home’ and they are ready to go,” said Joyce. “That’s not the time when we want to start doing the education for the discharge process.” She believes that discharge begins at admission, and being able to standardize and streamline the discharge process throughout the patient’s stay will increase the likelihood that patients will remember important medication information.

Collaboration is also an important element of medication education in terms of engaging patients, families, and caregivers. “It’s really amazing—the difference between what the patient hears and what a family member hears,” said Joyce. Collaboration should also occur between patients and their families, health care providers, and community connections to help eliminate barriers to a successful transition from the hospital to another health care setting. “Now is the time for all of us to work together because our patients are suffering,” said Joyce.

Making a difference

One group of researchers found that something as simple as a phone call made by a pharmacist to a patient after discharge from the hospital reduced readmissions and increased the hospital’s financial savings. A study published in the January/February 2013 Journal of the American Pharmacists Association assessed the impact of clinical pharmacist medication therapy assessment and reconciliation for patients postdischarge in terms of hospital readmission rates, financial savings, and medication discrepancies. Researchers followed patients who were at high risk for readmission at Group Health Cooperative in Washington State from September 2009 through February 2010. Patients in the medication review group (n = 243) received a phone call from a pharmacist 3 days to 7 days postdischarge for medication therapy assessment and reconciliation. Patients in the comparison group (n = 251) did not receive clinical pharmacist intervention.

The investigators reported that patients who received medication therapy assessment and reconciliation had decreased readmission rates at 7, 14, and 30 days postdischarge. Financial savings for Group Health per 100 patients who received medication reconciliation were an estimated $35,000, translating to more than $1,500,000 in savings annually. “The findings support the role of pharmacist medication therapy assessment and reconciliation as a key step in the transitional care process from hospital to home,” wrote the researchers.

REACHing out

In an effort to reduce readmissions for patients with heart failure, Einstein Medical Center in Philadelphia developed a program called REACH (Reconciliation, Education, Access, Counseling, Healthy Patient at Home), which focuses on medication reconciliation, education about medications provided by pharmacists at discharge, and follow-up calls after discharge.
Launched in 2010 and funded by a grant from the Albert Einstein Society, the health system’s internal foundation, REACH is a multidisciplinary initiative involving nurses, nurse managers, social workers, care management, physicians, and pharmacy residents. An article that recently appeared on noted that according to internal studies at Einstein, the REACH program cut the health system’s readmissions for patients with heart failure within 30 days of discharge by 50%.

Resources for pharmacists

Although health care providers at Einstein developed their own strategy to reduce readmissions, many tools and guides are available to assist hospital pharmacists. For example, the Agency for Healthcare Research and Quality’s Project RED (Reengineered Hospital Discharge) intervention is a 12-step standardized approach to discharge planning and discharge education, where pharmacists have an important role in helping patients understand and adhere to their medications. (For more information about Project RED, see page HSE 8 in the January 2013 Pharmacy Today Health-System Edition.)

Another program is the Society of Hospital Medicine’s Project BOOST (Better Outcomes by Optimizing Safe Transitions). This national initiative is designed to improve patient care during the transition from hospital to home. Project BOOST can help reduce readmissions by helping hospitals map out and create actions plans for organizational change. The program also provides a toolkit of clinical interventions that can be adapted for any hospital setting. The Project BOOST toolkit was downloaded by more than 1,600 sites as of December 2010. According to the society’s website, early data from sites that implemented Project BOOST show a reduction in 30-day readmission rates from 14.2% before Project BOOST to 11.2% after implementation.

The Institute for Healthcare Improvement (IHI), based in Cambridge, MA, developed a how-to guide for improving transitions of care to reduce avoidable rehospitalizations as part of the STAAR (State Action on Avoidable Rehospitalizations) initiative. The guide supports hospital-based teams and their community partners in collaborating on the development and implementation of improved care processes to ensure that patients who have been discharged from the hospital have a smooth transition to the next setting of care, whether it is their primary care physician, a skilled nursing facility, or home care.

STAAR initiative

In 2009, IHI launched the STAAR initiative for health systems in Massachusetts, Michigan, and Washington State. The goal of the initiative is to provide support and assistance to health and multidisciplinary teams to improve transitions in care and reduce avoidable rehospitalizations. More states and regions will be added as the program grows.

Joanne Doyle Petrongolo, PharmD, clinical pharmacist for the Integrated Care Management Program at Massachusetts General Hospital in Boston, gave a presentation about her experience with implementing the Care Management Program (CMP) in conjunction with STAAR at a session on sustainable approaches for reducing 30-day hospital readmissions at the 2012 American Society of Health-System Pharmacists Midyear Clinical Meeting. Both the STAAR initiative and CMP are multidisciplinary efforts that span the hospital and outpatient settings.

Mass General initiated the STAAR program in 2009 on three hospital floors with the goal of reducing readmissions through interventions such as medication reconciliation, postdischarge calls, and postdischarge visits. “It took a village,” Petrongolo told conference attendees. “We had a [cross-continuum] team of multidisciplines that were involved including pharmacy, case management, nursing, medicine, physical therapy, you name it.”

Before implementing the STAAR initiative, Mass General launched CMP, which started as a Medicare demonstration project in 2006 with 3,000 high-risk Medicare patients who were managed by case managers embedded in primary care practices. CMP was a team effort comprising pharmacists, social workers, and other health care workers. “After 3 years, we were able to show a reduction in [emergency department] visits by 13%, a reduction in hospital readmissions by 20%, and showed a cost savings of $2.65 per dollar spent to Medicare,” said Petrongolo.

Pharmacist roles

Pharmacists played important roles in both the CMP and STAAR initiatives at Mass General. During predischarge, pharmacists performed medication reconciliation upon admission, provided inpatient monitoring, communicated with the discharge nurse and case manager, and reviewed the final medication list with the patients or caregiver.

As part of the STAAR initiative, pharmacists contacted patients within 48 hours to 96 hours after discharge. Pharmacists also performed a postdischarge medication review. According to Petrongolo, the readmission rate for patients who received pharmacist calls was 13% versus 17% for patients who did not receive a call. In addition, noted Petrongolo, predischarge interventions conducted by pharmacists have shown a reduction in readmission rates from 27% to 16%. “The buck stops here,” said Petrongolo. “If you have a pharmacist involved, [then] you can dramatically reduce the readmission rate by having interventions.”

Helpful resources

Several programs and strategies are available to guide pharmacists in their efforts to reduce rehospitalizations. For more information or to download toolkits, please visit the following:
Project BOOST
Project RED
STAAR initiative