Experience Brief: Desert Hospital Outpatient Pharmacy partnering with hospital to reduce readmissions among CHF patients

Mr Upadhyayula

Desert Hospital Outpatient Pharmacy is an independent pharmacy inside Desert Regional Medical Center, a 387-bed tertiary acute care hospital located in Palm Springs, California. Desert Regional Medical Center, which has attained the Joint Commission’s Gold Seal of Approval for its congestive heart failure program, has reduced readmission rates by 17% among congestive heart failure (CHF) patients through a close partnership with Desert Hospital Outpatient Pharmacy.

Background

Desert Hospital Outpatient Pharmacy sees a diverse mix of patients. Approximately 40% of our pharmacy patients come from the hospital and associated accountable care organization, 50% are from the surrounding medical complex, and the remaining 10% come through word of mouth or referrals from other pharmacies and service providers. Professional referrals are often made when a patient needs a specialty medication, like chemotherapy drugs, which are not routinely stocked at neighborhood pharmacies. Because we are located within the hospital complex, we have these medicines on hand.

In general, we estimate that approximately 80% of our patients aged 65 years and older suffer from chronic illness, with CHF being the leading illness among this older patient population. Diabetes mellitus has quickly grown to be the leading chronic illness among our younger patient population ranging in age from 19 to 39 years. This age group accounts for approximately 25% of our overall diabetic patient population. As a result, a large number of our chronic disease patients are routinely prescribed 15 to 20 medications to be taken on a daily basis, which presents a huge challenge in terms of patient education and adherence.

Our pharmacy staff is comprised of 3 clinical pharmacists and 10 support staff. They fill on average 500 prescriptions a day and serve over 1,000 patients per month.

Experience

Our analysis shows that nearly 25% of CHF patients, 19% of myocardial infarction patients, and 18% of pneumonia patients were readmitted to the hospital within 30 days, placing a staggering financial burden on the healthcare system. While looking for areas to demonstrate an impact on patient outcomes and the bottom line for our extended healthcare system, we seek to keep our CHF patients healthy and at home following discharge from a hospital stay.

We initially rolled out our robust medication adherence program in early 2013, combining elements from the National Community Pharmacists Association’s synchronization program, Simplify My Meds, with automation technology and adherence strip packaging. In addition, our clinical pharmacists play a critical role in the success of our program. They are specially trained to partner with the extended healthcare team, including physicians, specialists, and other providers, and to work directly with patients to ensure all medications are taken as prescribed, providing the best health outcomes. Our clinical pharmacists drive patient engagement through one-on-one education, counseling, coaching, and regular communication.

Although our pharmacy is independent within the Desert Regional Medical Center, we work closely with the hospital steering committee, physicians, and other providers to ensure the highest possible medication adherence rates and patient outcomes. We carefully follow discharge protocols the steering committee has set in place and also with the physicians’ orders. As part of this partnership, CHF patients are automatically enrolled on discharge into our medication adherence program.

When a CHF patient has been identified for discharge, a nurse coordinates discharge orders with the treating physician and extended healthcare team, including one of our clinical pharmacists. The nurses typically send orders to our pharmacy using e-script, but in the case of a CHF patient, they manually fax the orders on a dedicated line with the patient clearly identified as “CHF.” When our team sees an order for a CHF patient, they immediately get to work filling the prescriptions needed for discharge.

A pharmacist delivers medications to the patient’s bedside and counsels the patient on the medication regimen, explaining how the strip packaging works and the importance of taking each medication according to date and time of dose. We also conduct a psychological and social evaluation to ensure there are no obstacles to adherence, providing solutions when appropriate. If a CHF patient is discharged outside of hospital hours, a pharmacist delivers medications to the patient’s home the following day.

A crucial element in maintaining a high adherence rate among chronic disease patients is ensuring those patients have access to their medications, regardless of their financial situation. As such, the hospital covers the cost of prescription co-pays for insured CHF patients for the first 30 days, while uninsured CHF patients are provided their first 30 days of medication free of charge. In addition to receiving 30 days of medication at discharge, CHF patients are also given a scale to monitor their weight for water retention, one of the initial warning signs of heart failure.

As pharmacists, we have the opportunity to have regular interactions with our patients and to provide them with ongoing encouragement and education. Through the use of automated technology, our pharmacists have the time necessary to develop these critical relationships. Every month prior to medication refill, our CHF patients are contacted and surveyed to determine any changes in their health history. This also serves as an opportunity to provide support and advice, and, as needed, we contact the treating physician to make medication changes.

Our adherence program has had a dramatic impact on patient adherence, readmission rates, and the hospital’s bottom line. Patients enrolled in our comprehensive program have an incredibly high adherence rate of 90% to 95%. At Desert Regional Medical Center, there has been a dramatic drop in 30-day readmissions of CHF patients who are enrolled in our adherence program. That rate is now under 10%, compared to the state’s average of over 15%, saving the hospital more than $500,000 to date.

Readmissions cost the system approximately $15,000 per admission and can result in fines with the Centers for Medicare and Medicaid Services (CMS) Hospital Readmissions Reduction Program. This program, a section of the Affordable Care Act, levies penalties against hospitals with excess readmissions within 30 days for CHF patients.

For pharmacists interested in reducing readmission rates, we have found the keys to our success include:

·         Adherence strip packaging, which provides patients with a convenient, easy-to-use, safe, and accurate system;

·         Automated technology systems that are predictable and consistent to help support improved outcomes;

·         One-on-one patient coaching and counseling; and

·         Constant, regular communication, both internally and with patients.

Our success is only reflected by our patients’ success. When an individual feels like an educated and supported member of their own healthcare team, they are more likely to adhere to their discharge program and medication regimen. Ultimately, with better adherence rates among our pharmacy patients, we can positively impact readmission rates and the hospital’s bottom line.

Mr Upadhyayula is the owner of Desert Hospital Outpatient Pharmacy located in Palm Springs, CA.

Disclosure Information: The author reports no financial disclosures as related to products discussed in this article.

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