The Hospital Readmissions Reduction Program (HRPP) which was established by the Affordable Care Act (ACA), imposes penalties on hospitals with excess readmissions and the potential financial burden on hospitals is a growing concern. Post-hospital medication adherence discrepancies that result in patient adverse outcomes is additionally alarming as well as lacking patient medication reconciliation plans or strategies among most hospitals. The post-hospital medication adherence discrepancies and the financial burdens faced by hospitals are problems that can be prevented to increase and improve the patient’s health and quality of life, as well as save hospitals billions of dollars that would, in turn, improve and enhance their own healthcare systems.
- Objective and Mission Statement
This White Paper’s objective and mission will aide hospitals in reducing readmissions by providing a bedside delivery service that will increase patient compliance.
The New England Journal of Medicine published a recent article stating that 1 out of 5 patients are readmitted within 30 days of discharge, costing $17.4 billion of Medicare’s current $102.6 billion budget.1
1.1. The main reason behind these alarming statistics is that patients are failing to fill their prescriptions after being discharged from the hospital. Not only do readmissions increase hospital operating costs, but they also result in a reduction to hospital patient satisfaction ratings that are largely based on patient survey results.
1.2. Implementing a bedside delivery program would:
- Reduce patient readmissions
- Improve patient adherence to medication(s)
- Reduce post-hospital medication errors
- Improve patient’s satisfaction ratings
1.3. The program would also enhance patient care services, provide a continuum of care from the hospital to home through community pharmacy care, reduce costs to healthcare systems and patients, and ensure regulatory compliance.
1.4. In a recent Patient Protection and Affordable Care Act (PPACA) report on policy options and issues concerning Medicare hospital readmissions, factors other than medication non-compliance leading to patient readmissions identified by the report included the following: unsatisfactory communication of medical and care‐ related information by hospital discharge planners to patients; poor patient compliance; and insufficient follow‐up care from care providers. In addition, and even more disconcerting, the PPACA report found that discharge medications were not
included in hospital discharge reports 60% of the time. Having scripts filled prior to a patient’s discharge will ensure that the script is included in a patient’s report which will, in turn, significantly reduce this percentage.
1.5. Additional tactics targeted at reducing readmission rates include the following: managing chronic diseases effectively in the outpatient setting; encouraging interdisciplinary collaboration; managing the health of the population; and monitoring progress with metrics.
2.0 LIFECARE Pharmacy’s Methodology and Solution
2.1. An optimal solution to the growing problem of hospital readmissions is to execute a bedside delivery program before patients are discharged at the hospital to: 1) reduce the number of hospital readmissions; 2) reinforce Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Joint CommissionK. SERVICES RECEIVED (Continued)
Case Management Services scores; and 3) raise health awareness and optimize the community healthcare support system to improve patient outcomes.
2.2. A recent Policy Section article that appeared in the Pharmacy Practice News, dated March 2013 issue, stated: “Pharmacists, as the medication experts, are really the best people to be assisting with the medication reconciliation process, including medication counseling for patients going home and ensuring access to new, needed prescriptions prior to leaving the hospital” (Ochoaet al., 2013)
2.3. Educational printed materials, discharge counseling, follow‐up calls (after a patient returns to their residence), and transmission of the script order to the patient’s local pharmacy are all very helpful, but providing a bedside delivery discharge script service is the best option available because it gives patient access to the medication prior to discharge.
2.4. Example 1:
Laura Britton, PharmD, BCPS, CACP, a pharmacy clinical coordinator in ambulatory care service at the University of Utah Health Care in Salt Lake City, was interviewed by Pharmacy Practice News and she stated that since discharge script services were initiated three to four years ago at both the University of Utah Hospital and the Huntsman Cancer Hospital, “We have seen a drop in readmissions. We found that we were making interventions in the discharge orders/prescriptions about 80% of the time at the main hospital and 100% at the cancer hospital, thus showing a tremendous patient safety need,” Britton added.
2.5. Example 2:
Chicago-based Mercy Hospital & Medical Center found it very challenging to ensure patients recovery at home to be safe and comfortable without readmission. Improving access to follow-up care is at the heart of Mercy’s efforts to reduce unnecessary readmissions and repeat emergency department visits. Many patients admitted by Mercy are high-risk patients, so they are in jeopardy of being readmitted after discharge. Recognizing that medication management issues tend to be one of the primary reasons behind preventable readmissions, hospital leaders turned to the pharmacy team to find a collaborative solution. Pharmacists bring unique clinical skills and expertise to care transitions that are key to helping patients achieve the greatest benefit from their medications. The pharmacy team implemented a pilot program at the Mercy Family Health Center to evaluate its capability to prevent 30-day hospital readmissions and repeat ER visits.
2.5a. While reducing readmissions by any degree was considered a triumph, the results posted within the first month of Mercy Family Health Center Clinic operations surpassed all of Mercy’s expectations (see Figure 1). Within the first month, readmissions of patients seen by the nurse practitioner decreased, and readmissions decreased even more significantly when the pharmacist and nurse practitioner saw the patient together.
Figure 1: Discharge Clinic Readmission Rates
2.5b. Mercy improved and sustained these results over the course of the first year of its discharge clinic’s operation:
- In the first month, only 3% of at-risk patients seen by both the pharmacist and nurse practitioner were readmitted within 30 days of discharge vs. 15% of post-discharge patients who were seen by the nurse practitioner alone [see FIgure 1].
- By the end of the first quarter, the readmission rate for at-risk patients seen by both the pharmacist and nurse practitioner dropped to 2% compared to 15% for at-risk patients seen only by the nurse practitioner.
- In the following three quarters, 0% of the at-risk patients seen by both the pharmacist and nurse practitioner were readmitted, versus 11%, 17% and 8%, respectively, for the same time periods for at-risk patients seen only by the nurse practitioner.
- As a whole, the discharge clinic experienced a drop in readmission rates for all its patients from 7% in its first quarter to 1% a year later.
2.5c. The ongoing operation of the clinic has contributed to Mercy’s ability to reach key quality measures by significantly reducing readmissions among their at-risk patient populations. Through this initiative, patients have acquired a better understanding of their medication regimens and health conditions, and now have access to the information they need to properly and confidentially care for themselves and recover at home.
The table below includes additional studies of pharmacist intervention at discharge.
3.0 Bedside Delivery: How it works… 3.1. The LIFECARE Bedside Delivery Program is a beneficial and successful tool that hospitals can (and should) take advantage of when discharging any patient, especially those with chronic conditions.
3.2. Here’s how it works…
- First, the patient is given the option for a bedside delivery service. If the patient elects to use the bedside delivery service, LIFECARE Pharmacy is notified of patient discharge.
- A dedicated LIFECARE Representative then gathers patient information and script details.
- Next, prescriptions are processed.
- Payment is then arranged with the patient or caregiver.
- Medication instructions are offered to the patient.
- The medications are delivered to the patient’s bedside.
- The patient receives a follow up call from the Pharmacist 48 hours after discharge.
- There is a pharmacist clinical therapy review approximately 10 days post-discharge.
- And finally, there is community integration provided by the pharmacist at 25 days post-discharge.
3.3. Taking the extra step to include bedside delivery in the transition of care will reduce hospital readmissions, improve patient safety, and enhance the patient’s discharge experience. Educating the nurses and doctors of the bedside delivery service and it’s benefits will be necessary in the roll out of the program. The pharmacy technician will ensure compliance with HIPAA policies, they will be cleared by the hospital’s HR department, trained, and will be issued a hospital badge to be worn when while in the building.3.4. LIFECARE Pharmacies are on the frontline of a new transition of care program, a bedside delivery service, which brings hospitals and health systems together with a well coordinated care model designed to reduce readmission rates and reduce overall healthcare costs, while improving patient health outcomes and medication compliance.In 2014, more than 25 million new patients will enter the U.S. health care system as a result of the Patient Protection and Affordable Care Act (ACA), driving the need for change.
3.5. This impacts medical facilities nationwide that face possible penalties from Medicare for patient readmission rates that are too high, under the ACA that took effect Oct. 1, 2012According to Washington Adventist Hospital in Maryland, of its first 48 high-risk patients enrolled in bedside medication delivery programs, only three were readmitted within 30 days of discharge.
3.6. Preventable hospital readmissions cost the U.S. healthcare system approximately $25 billion per year, as stated in a Pricewaterhouse Coopers’ Health Research Institute study. Bedside Pharmacy Services are now available to patients at a growing number of locations, including Sarasota Memorial Health Care System, Washington Adventist Hospital in Takoma Park, Md., and Marion General Hospital in Marion, Indiana.3.7. As many hospitals and medical centers place a greater emphasis on reducing patient readmissions, pharmaceutical companies are aiming to broadly roll out the program to other facilities throughout the U.S., including more than 150 hospitals and health systems nation wide. LIFECARE Pharmacy would like to implement this in San Antonio and throughout Texas.3.8. The LIFECARE Pharmacy Bedside Delivery Program offers a number of services, including:
- Medication review – pharmacists review patients’ prescriptions upon admission to the hospital and at discharge, and check for potential interactions and simplification of medication regimen
- Bedsidemedication delivery – LIFECARE pharmacy technicians deliver medication(s) that the patient will need to take after discharge directly to the patient’s hospital room before discharge, and offer medication education and instructions
- Patient counseling – pharmacists provide medication counseling to both the patient and caregiver and work in close communication with the medical staff
- Regularly-scheduled follow-up calls – pharmacists conduct regular calls to follow up on patient progress, discuss regimens and answer any questions or concerns
- Reducing hospital readmissions is our majorgoal
- Specialty Packaging (Ex. Below)
3.9. San Antonio local hospitals are under increasing pressure to deliver high-value health care. For that reason, LIFECARE Pharmacy Bedside Delivery Program is at the cutting edge of innovative, cost-saving approaches to coordinated and integrated healthcare. With the recent implementation of the Affordable Care Act (ACA), more focus has been placed on the coordination of care and reducing unnecessary medical costs. In response to a provision within the ACA, the Centers for Medicare and Medicaid Services (CMS) enacted strategies to reduce readmissions and curb unnecessary costs. CMS will not fully reimburse for a related diagnosis, such as myocardial infarction, chronic heart failure, or pneumonia, if readmission occurs within a 30-day period. Currently, the penalty associated with a readmission is a reduction in the reimbursement rate, which is presently 2% and will increase to 3% for FY 2016. Due to the high volume of high-risk patients being discharged at many hospitals, LifeCare pharmacists will collaborate with hospital discharge staff to coordinate patient medication discharge education. 4.0 Outcomes and Takeaways in Hospital Institutions and Patient Care Facilities 4.1 The bedside delivery service is remarkable for so many reasons. Implementing a program that delivers medications to a patient’s bedside prior to discharge ensures that the patient has access to their prescriptions before they return home, can improve medication adherence, and has the potential to reduce readmission rates. Data indicates that only about 40% of patients fill their prescriptions the day of discharge, and 22% do not fill their prescriptions by a median of 12 days after discharge. Patient-reported barriers included lack of transportation, difficulty affording medications, and long wait times in the pharmacy.4.2. The following are benefits relating to the bedside delivery service:
1. Convenience. The patient receives the medications before leaving the hospital. Our patients and their families love this service.
2. Compliance. We know that the prescription was actually filled. The literature shows that many prescriptions that are written are never filled, which reduces medication compliance, increases the cost of healthcare and ultimately decreases the quality of life for patients.
- Medication Adherence due to easy to follow specialty packaging. Patients will not get confused on which medication to take, which dosage to follow nor time of day most optimal for outcome.
- A significantdecrease in readmissions to an already burdened hospital team.
- Overall decrease in the cost of care and savings to hospitals.
5.0 Executive Conclusion
5.1. There is evidence in the research that pharmacy bedside delivery services reduce readmission rates and improve medication compliance among patients. Collaborative practices are evolving that include greater pharmacist responsibility for prescribing medications as part of coordinated health care teams in hospitals and clinics. It is evident that patient medication adherence must receive a much greater emphasis. Ensuring that recently discharged patients recover safely and comfortably at home is one of the primary objectives of every hospital; yet, it can prove challenging. LIFECARE Pharmacy Network’s bedside delivery program is one of the solutions to address discharged patients medication compliance, satisfaction levels as well as reducing their chances for readmission. As hospitals aim to decrease their readmission rates and increase patient medication compliance, prescription management and reconciliation have taken on an increasingly significant role. Hospitals will be turning to their community pharmacies to assist in reducing readmission rates. As medication experts, community pharmacies are fundamental and should be proactive in collaborating, analyzing and implementing medication management programs in the hospital discharge and post-discharge follow up proceduresFor additional information call Eduardo J. Guimbarda, MBA (Business Strategist and Healthcare Consultant): 210-771-5656 or our corporate office to speak to a representative at LIFECARE Pharmacy Network: 210-881-0890. Or, you may reach a LIFECARE team member directly at any of the contacts listed below:
Prem Kalidindi, R.P.H: 917-769-8014 April Kappus (Business Development Manager): 210-765-7633 Tony Duran (Marketing Coordinator): 210-269-4003 Lifecare Pharmacy Network P.O. Box 12929 San Antonio, TX 78212 www.lifecarepharmacy.com REFERENCES
- Stephen F. Jencks et al., Rehospitalizations Among Patients in the Medicare Fee- for-Service Program, 360 NEW ENG. J. MED. 1418, 1426 (2009)
- 2014 National Patient Safety Goals. The Joint Commission. www.jointcommission.org/standards_information/npsgs.aspx.
- Readmissions reduction program. CMS. Updated August 2013. www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html.
- Teaching Aids. The Teachback Method. NC Program on Health Literacy. 2013. www.nchealthliteracy.org/teachingaids.html.
- Swarthout MD. Building a pharmacist-led medication management transitions of care program in a health system. Presented at: North Carolina Association of Pharmacists; October 2013; Raleigh, NC.
- Marcum C, Milner J, O’Connell M. Creating a hospital-based bedside delivery program to enhance the experience at Cleveland Clinic. Presented at: American Society of Health-System Pharmacists Midyear Clinical Meeting; December 2013; Orlando, FL.
- Brookes K, Scott MG, McConnell KB. The benefits of a hospital based community services liaison pharmacist. Pharm Sci World. 2000;22:33-38.
- Newman C, Haight R, Hoeft D. Implementation and impact of pharmacist led medication reconciliation and patient education at discharge from an inpatient behavioral health unit. Ment Health Clin. 2013;3:96.
- Bellone JM, Barner JC, Lopez DA. Post discharge interventions by pharmacists and impact on hospital readmission rates. J Am Pharm Assoc. 2012;52:358-362.
- Thompson CA. Pharmacy departments innovate to reduce readmissions penalty. Am J Health Syst Pharm. 2013;70:296-298.
- Outpatient Pharmacy. State of Pharmacy Automation Survey. Pharm Purch Prod. 2013;10(8):88-90.
- ASHP Pharmacy News. Medicaid Reform Causes Major 340B Program Changes in Illinois.http://www.ashp.org/menu/News/PharmacyNews/NewsArticle.aspx?id=3762 Accessed May 14, 2014.
- Kripalani S, Henderson LE, Jacobson TA, Vaccarino V. Medication use among inner-city patients after hospital discharge: patient-reported barriers and solutions. Mayo Clin Proc. 2008;83(5):529-535.
- Knoer S. Stewardship of the pharmacy enterprise. Am J Health-Syst Pharm. 2014; 71: 1204-9.
- Fischer MA, Stedman MR, Lii J, Vogeli C, Shrank WH, Brookhart MA, et al. Primary medication non-adherence: Analysis of 195,930 electronic prescriptions. J Gen Intern Med. 2010; 25 (4): 284-90.
- CMS Final Rule and Hospital Readmissions Reduction Program http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ AcuteInpatientPPS/Readmissions-Reduction-Program.html/
- Partnership for Patients http://partnershipforpatients.cms.gov/
- Computer Science Corporation. “Preventing Hospital Readmissions: The First Test Case for Continuity of Care.”
- AMDA Clinical Practice Guideline for Transitions of Care http://www.amda.com/tools/clinical/toccpg.pdf
- STAAR Initiative (State Action on Avoidable Rehospitalizations) http://www.ihi.org/offerings/Initiatives/STAAR/Pages/ Approach.aspx CMS Community-Based
- Care Transitions Program (CCTP) http://innovation.cms.gov/initiatives/CCTP/
- Preventing Readmissions with Help from Pharmacists http://www.hhnmag.com/articles/3391-preventing-readmissions-with-help-from-pharmacists
- American Medical Directors Association. “Clinical Practice Guideline for Transitions of Care.” Available at http://www.amda.com/tools/clinical/toccpg.pdf. Accessed December 21, 2014