How Health Systems Use Pharmacists to Reduce Readmissions

With readmission rates on the line due to the ACA’s 2012 Hospital Readmission Reduction Program (HRRP)-which imposes penalties for higher-than-expected risk-standardized, 30-day unplanned readmission rates for six conditions-hospitals would be remiss if they didn’t establish an effective program to improve their measures.

The Medicare Payment Advisory Council (MedPac) estimates that 12% of readmissions are potentially avoidable. Preventing even 10% of them could save Medicare $1 billion.

As pharmacists move farther away from their traditional role of only dispensing medications and accept responsibility for medication therapy management, hospitals are leveraging their expertise and placing them at the forefront of readmission reduction programs.

Role of pharmacists in readmissions programs

Eric Maroyka, PharmD, director, Center for Pharmacy Practice Advancement, ASHP, believes that pharmacists could play many roles in readmissions programs:

• Conducting full medication reconciliation from hospital admission through discharge.

• Offering recommendations, such as eliminating unnecessary or harmful medications, optimizing dosing, and suggesting alternative therapies to a medical team.

• Making changes independently to medication therapy based on practice scope and collaborative practice agreements.

• Assisting with care coordination and patient navigation near the time of discharge, providing patient education, and scheduling follow-up visits for medication management services.

• Coordinating with pharmaceutical assistance programs, insurance carriers, and community or outpatient pharmacies to access and afford medications.

• Ensuring medication adherence.

“An interprofessional and complementary approach using the pharmacist as the medication expert will add a necessary dimension to ensure an experience every patient deserves to improve access, cost, quality, and overall interprofessional team resilience,” Maroyka says.

While he has pinpointed the extensive role of pharmacists in readmission reduction programs, Maroyka is well aware of the challenges of such endeavors.

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“Electronic health record interoperability remains a significant barrier across patient care settings,” he says. “This contributes to communication breakdowns and making less-informed decisions about patient care when accessing disparate data systems with incomplete or incorrect patient information.

“In addition, it is necessary to ensure staff competency enabling the pharmacy to have the capability and capacity to consistently support interprofessional care transition efforts across a continuum of care,” Maroyka says.

Pharmacists at BayCare

BayCare Health System, a not-for-profit healthcare system in Tampa, Florida, introduced its Pharmacy Transitions of Care Program (PTOC) as a pilot in 2014, with two pharmacists in one of its 15 hospitals. The program has since grown to 23 pharmacists and has expanded to all its hospitals. It targets Medicare A and B beneficiaries with primary diagnoses of a CMS core measure who are discharged from a hospital to home or an assisted living setting.

Timothy L’Hommedieu, PharmD, director of pharmaceutical services, East Region, BayCare Health System, credits the healthcare industry’s shift to value-based care for the initiation of PTOC. 

“The program’s goal is to decrease 30-day hospital readmissions. With drug therapy as the best way to treat acute and chronic conditions, the program provides an opportunity for pharmacists to play a significant role in transitional care,” he says.

Participating pharmacists are specially trained in ambulatory and transitions of care and hired just for that role, L’Hommedieu says. They are board certified and/or have received residency training­.

Collaborating with inpatient and outpatient care teams-which include social workers, home care experts, and physicians-pharmacists conduct two patient visits after discharge and telephonic encounters within seven and at 21 days after discharge, providing comprehensive medication review, medication therapy management, and counseling.

They also evaluate patient clinical status, help identify and solve any problems with medications-side effects, wrong dose, or inappropriateness or ineffectiveness-and ensure patients understand their medications and can afford and access them.

“Clinical pharmacists have always assumed these responsibilities but not in the transitional setting. BayCare has specifically invested in them to provide these services,” L’Hommedieu says.

The health system conducted a study using data from September 2016 to May 2017, comparing 2,200 patients eligible for a readmission penalty enrolled in PTOC with a control group of 1,335. The readmission rates were 8.3% versus 23.7%, respectively. Pharmacists documented 13,855 interventions (including 1,503 contacts with members of the interdisciplinary team), delivered 175 medication assistance programs, and provided 12,177 counseling interventions.

The program demonstrated a 63% relative reduction in all-cause readmission rates during that time period.

Although L’Hommedieu says HRRP is not the primary reason for developing the program, he is aware that results are publicly reported and can influence which hospitals patients select. “The law serves as justification for our investment in the value-based PTOC, which serves as a support program offering optimal patient outcomes,” he says. “If we deliver best practices, we set our patients up for success, and we can reduce readmissions.”

He emphasizes the importance of the team-approach to reducing readmissions, but admits it isn't always easy to coordinate such a group and provide a seamless experience for patients.

Dignity Health Northridge targets chronic disease

Dignity Health-Northridge Hospital Medical Center’s chronic disease transitional care program involves a team of physicians, nurse practitioners, nurses, social workers, and pharmacists who collaborate with an inpatient care team. They provide clinical oversight and discharge planning for a chronic disease population during a hospital stay and for 30 to 90 days after discharge.

After discharge home or to a long-term care environment, the team provides clinical oversight to patients in conjunction with external community partners, such as home health agencies and local pharmacies, and focuses on patient safety, health, satisfaction, and mitigation of avoidable readmissions.

By using an interdisciplinary approach to care, pharmacists can reach out to other experts on the team to help develop an individualized care plan and assist in creating strategies to support positive patient outcomes, says Jasmen Esfandi, PharmD, clinical pharmacist for the program.

Northridge in Southern California initiated the program in 2015, as an enhancement to its palliative care program, spreading population health and care throughout the continuum of chronic disease.

“The objective is to address an aging population within the community, ensuring a safe and appropriate level of care for patients after discharge and promoting self-care management,” Esfandi says.

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The number of patients affected by the program has nearly doubled to 7,300 since its inception.

Through medication therapy management, pharmacists and nurse practitioners provide recommendations for changes in patient medication regimens based on diagnoses. Pharmacists also perform discharge medication reconciliation for patients returning home or transferring to one of Northridge’s skilled nursing facilities.

If discrepancies or errors in medications-incorrect doses, drug interactions-are found, physicians join pharmacists in resolving problems.

Pharmacists take an additional step by making home visits to help patients understand their medication, ensuring patients have access to their medications, can account for any missing drugs, and know how to administer them.

Like pharmacists in similar programs, Esfandi says data collection is one of her biggest challenges; prompting the hospital to engage data coordinators to collect measures that communicate productivity, efficiency, and positive outcomes of the program.

She also agrees with her colleagues that while HRRP has helped drive the transitional care program, presenting estimated Medicare penalty savings indicates the effectiveness and value of the program.

Northridge has experienced a yearly decrease in readmission rates of 10% over the previous year. Esfandi says these rates are aligned with California goals.

Einstein REACH Program takes off

After a pilot targeting adult patients admitted to a cardiac care unit from 2010 to 2011, Einstein Medical Center in Philadelphia developed its Medication REACH (Reconciliation, Education, Access, Counseling, Healthy Patient at Home) intervention in 2012, with a single pharmacist.

Since that time, Einstein has incorporated transition of care services into existing clinical pharmacist roles. Pharmacists collaborate with physicians, residents, and nurse practitioners from admission through post-discharge. The center added two pharmacy technicians, one to complete medication reconciliation in the emergency room and one as a discharge liaison to facilitate access to medications at the time of discharge.

The primary goal is to reduce hospital readmissions by improving medication management in the hospital, home, and during transition from these settings.

A 667-patient study, which appeared in the May 1, 2018 issue of American Journal of Health-System Pharmacists, evaluated whether REACH was feasible as part of routine care at a safety net hospital and could reduce hospital readmissions for Medicare fee-for-service.

Using a multifaceted approach, Einstein sought to Improve medication management through direct pharmacist involvement and multidisciplinary communication between pharmacists and a clinical team.

Pharmacist intervention included reconciling medications, patient-centered education, ensuring access to medication, and follow-up at patients’ homes.

The study compared 30-day readmissions in patients with full and partial intervention with those receiving standard care. The results indicated 9.8% unplanned readmissions for the managed group versus 20.4% for the control group.

“It is important to establish collaboration not just between pharmacists and a medical team but also with care managers, insurers, and community pharmacists,” says Mariel Shull, PharmD, pharmacy utilization management coordinator for NYU Langone and the dedicated pharmacist in the Einstein study and its coauthor.

She sees pharmacists as an ideal fit for their role in a transition of care program that demands continuous coordination because of its complexity. “Pharmacists are medication experts that can ensure access to medications, improve adherence, and monitor patients.

“It is important to measure impact to support expansion of services and advocate for resources, but efficient documentation is difficult or challenging in many existing electronic medical records,” says Shull, concurring with Esfandi.

Shull also agrees with L‘Hommedieu that a readmissions program helps justify involvement of pharmacists and makes a business case for the program.

“Hopefully, pharmacists and other team professionals will adapt this kind of transition of care model to other programs used in everyday care,” Shull says.

Mari Edlin, a frequent contributor to Managed Healthcare Executive, is based in Sonoma, California.