The role of the pharmacist in preventing hospital readmissions

November 4, 2014

A community pharmacy group in Clinton, Iowa, shares its formula for improving medication adherence and patient outcomes while reducing hospital readmissions and healthcare costs.

At Wagner Pharmacies, with four locations in Clinton, Iowa, we have developed an industry-leading, data-driven clinical program for improving patient outcomes within the new healthcare landscape. Focused on supporting our patients in medication therapy management and medication adherence, board-certified ambulatory care pharmacists have played a central role in the development of this program.

Background

Healthcare reform is creating a shift away from volume-based to value-based care, with a renewed focus on improving patient outcomes and quality care. As trusted medical professionals with frequent access to patients, pharmacists are uniquely positioned to play a key role in positively affecting patient outcomes and reducing hospital readmissions, as well as ultimately reducing healthcare costs.

Under the Affordable Care Act, hospitals are measured on performance with the Hospital Readmissions Reduction Program (HRRP). HRRP, administered by the Centers for Medicare and Medicaid Services (CMS), penalizes hospitals with excess readmissions and admissions within 30 days of discharge for a number of conditions, including pneumonia, heart failure, myocardial infarction, and joint replacement. This year, close to 80% of the 3,400 hospitals evaluated received financial penalties projected to cost an estimated $428 million in fiscal year 2015.1,2 It is possible that penalties could be avoided through greater medication adherence. 

Why is it an issue when nonadherence follows an inpatient procedure or a hospital stay? A 2013 study showed that medication nonadherence costs the U.S. healthcare system an estimated $290 billion annually in unnecessary spending.3

Experience

Patients are often discharged from the hospital following an inpatient stay with several new prescriptions and a new medication regimen, and the new medications are often additions to what the patients were already prescribed for preexisting chronic conditions.

We see patients in our pharmacies who have not received sufficient in-hospital education to understand what each medication is for or how the new medications will interact with existing medications. Moreover, they may not be willing (or able) to pay for all of the various drugs prescribed. Once a patient leaves the facility, the prescribing physician is often no longer in communication with the patient, and the patient is left to make key decisions about the medication regimen that are based on a lack of understanding or financial constraints, or both.

In our experience, decisions an individual makes at the pharmacy counter can have a negative impact on medication therapy and subsequently on health outcomes, an impact that frequently leads to hospital readmission. In turn, such hospital readmissions incur financial penalties for the institution and hurt the hospital’s bottom line.

We believe that pharmacists can improve outcomes and reduce readmissions through implementation of a robust medication adherence program supported by patient education and internal communication. Our pharmacies have had great success through a program we developed called "MedAssist," which uses the following tools:

·      Industry data on the effectiveness of medication synchronization and adherence programs

·      Ongoing staff and patient education

·      One-on-one patient interviews with a clinical pharmacist

·      Adherence packaging that simplifies medication regimens

 

The program

One of the best practices we follow when first enrolling a patient in our medication adherence program is having a clinical pharmacist meet with the patient in a free evaluation. Each of our locations has a board-certified ambulatory care pharmacist; these specialists are trained in integrated care and strive to build long-term relationships with patients.

Together, our pharmacists and patients review the list of prescribed medications and discuss directions for their use, as well as any side effects the patients may experience. Our pharmacists make it a standard practice to follow up with physicians as needed to make any necessary changes to patients’ medication regimens. If a patient has been hospitalized, our pharmacists find it helpful to increase the number of one-on-one interviews. Having a team member follow up with patients after discharge and appointments with their primary care physician ensures that we have the most up-to-date information about the individual’s medication therapy. In our experience, this is especially critical when we help someone manage a chronic illness such as diabetes mellitus or heart disease.

Another key to our patients’ success is medication adherence packaging. Using strip-packaging technology that we call “MedPack,” prescription medications and over-the-counter drugs are packaged for each patient according to day and time of dose. This makes it easy for our patients to comply with medication regimens and simplifies adherence for both patients and caregivers.

Patients enrolled in our program pick up medications once a month. Our pharmacists place calls to each program participant before they pick up their medications, at which time the patient can check in and share therapy updates or changes so that any necessary adjustments can be made. Patients love the convenience, and caregivers have found that this helps them support patients at home, so that patients are less likely to move to rehabilitation facilities or long-term care.

We have found these practices helpful in ensuring adherence among our pharmacy patients, especially among those who have been recently discharged from a hospital stay. We are always evaluating new technologies, educational opportunities, and other strategies to improve our patient outcomes and ultimately reduce the number of our patients who must be readmitted based on nonadherence.

An initial evaluation of our program has shown dramatic increases in medication adherence. We recently studied 50 patients who took five or more medications for chronic illness and had been enrolled for 6 months or longer in our MedAssist program and MedPack strip-packaging program. We evaluated the baseline proportion of days covered (PDC) to establish patient adherence prior to initiation of MedAssist. We then evaluated each participant’s PDC during the first six months of participation and compared the difference between these values. The results show a significant increase in medication adherence, with an average increase in PDC of 52% after enrollment in our MedAssist program.

 

 

Average % increase in PDC by chronic condition

 

SubpopulationNumber of  PatientsBaseline PDC before enrollmentAverage % Increase in PDC after enrollment
Coronary artery disease1668%74%
Congestive heart failure1267%73%
Diabetes2169%62%
Hypertensives4571%55%
Hyperlipidemics4073%54%

Abbreviation: PDC, proportion of days covered

On the basis of these results, we are confident that our program can help additional patients successfully manage their health. We plan to add additional patients to MedAssist in the near term, but will do so slowly to ensure that we can continue to deliver the same high-quality level of care.

As the U.S. healthcare system continues to make this strategic shift to value-based care, pharmacists face new challenges and look forward to new opportunities. In our view, there are several areas in which pharmacists stand to add the most value to their patients and care communities, including medication adherence, improved patient outcomes, and reduction of avoidable healthcare costs.

Pharmacies are conveniently located where people live, work, and socialize. With easy access to patients and trusted expertise in medication management, pharmacists are perfectly positioned to empower patients to lead healthier lives. Providing quality service with an emphasis on these aspects of care will lead to success for both patients and pharmacists.

References

1. Kaiser Health News. Medicare readmissions penalties by hospital (year 3). http://capsules.kaiserhealthnews.org/wp-content/uploads/2014/10/Readmissions-Year-3.pdf?referrer=search. Accessed October 30, 2014.

2. Adamopoulos H. Readmissions penalties will cost hospitals $428M in FY 2015. Becker’s Hospital Review. October 2, 2014.

http://www.beckershospitalreview.com/finance/readmissions-penalties-will-cost-hospitals-428m-in-fy-2015.html. Accessed October 30, 2014.

3. CVS Caremark. 2013 state of the states: adherence report.

. Accessed October 30, 2014.

Tim Wright is owner and president, and Nora Wright is vice president, chief operating officer, and director of ambulatory care of Wagner Pharmacy Company in Clinton, Iowa.

Disclosure information: The authors report no financial disclosures related to products discussed in this article.