Targeting better patient outcomes through care transitions, adherence
Here’s a fact that keeps health plan administrators and anyone else responsible for budgeting health costs awake at night: 1-in-5 hospital patients ends up back in the hospital within 30 days of their discharge. And the biggest factors pulling them back all have to do with medications — either through medication errors, nonadherence or adverse drug events.
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That’s according to the Centers for Medicare and Medicaid Services, which put the cost of those revolving-door readmissions at $25 billion or more a year. Other estimates peg the cost as high as $44 billion, according to physician Stephen Jencks, a health consultant and senior fellow at the Institute for Healthcare Improvement.
Many of those costly trips back to the hospital could be avoided, said Jencks and other health experts, if there were better systems in place for transitioning patients from the hospital to the home or long-term care center — and improved coordination of care between the hospital and a local safety net of health providers, including pharmacies, clinics and physician groups.
In recent years, a number of pharmacy companies, big and small, have stepped up to prove that theory correct, developing innovative partnerships with local hospitals and health systems, all built around one fairly simple idea: getting the community pharmacist more actively involved in a patient’s transition from the hospital to the home, and helping them understand the critical importance of taking their medications as their doctors have prescribed. The results to date have been impressive, driving down 30-day hospital readmission rates about 50% for patients who have been part of these programs.
Plenty of factors are fueling the push for more coordination between hospitals, community pharmacies and other health entities. Among them is the critical need among public and private health plan payers to curb the staggering costs of hospital care.
“High-cost hospital care ... is a major driver of national health expenditures,” said Karen Utterback, VP of strategy and business development for McKesson’s Extended Care Solutions Group. “If you want to tame national health expenditures ... you must lower inpatient hospitalization rates.”
Also driving the transitions-in-care movement are the health reform dictates spawned by the Affordable Care Act of 2010, including the focus on quality of care and the shift in payments by Medicare and Medicaid from fee-for-service to outcomes-based reimbursements.
“With value-based hospital payment penalties now in place for excessive 30-day readmission rates, and a call for improved care coordination by the Affordable Care Act, improved models of care are necessary,” noted the American Journal of Managed Care.
“The ACA added force to new payment models that reward outcomes and penalize poor performance, such as high rates of readmission and hospital-acquired conditions,” agreed PricewaterhouseCoopers in a 2015 report on new health trends. “The ACA fueled this trend. For providers, the law took steps to change how Medicare pays for care by offering financial incentives and penalties that encourage better care coordination, higher-quality outcomes and less fragmentation.”
Indeed, the White House is pushing for federal health reimbursement changes “that would put as much as half of what it spends on Medicare into alternative payment models by 2018,” PwC’s Health Research Institute reported.
That shift away from fee-for-service to outcomes-based payments to hospitals is accelerating their urgent drive to discharge patients back into the community care setting more quickly and spread the risk burden among a team of community-based provider partners.
Pharmacists ‘at core of transitional care’
The stampede toward a more seamless transition of care between the hospital and the home is right in line with what Paul Abramowitz, CEO of the American Society of Health-System Pharmacists, called the “continued movement toward quality and coordinated delivery of care.”
“Studies have demonstrated that successful coordination and management of transition of care services lower costs by positively impacting hospital read mission rates,” Abramowitz said. “When pharmacists are involved, access is increased, quality is improved and costs are reduced.”
Anne Burns, VP of professional affairs for the American Pharmacists Association, agreed with that assessment. “We’re moving to a value-based healthcare system where providers, hospitals and other organizations are going to be paid based on their ability to both generate positive outcomes and control costs,” Burns said. “New care delivery models, such as patient-centered medical homes, are expanding across the country. Pharmacists are increasingly being incorporated into these models as members of inter-professional healthcare teams that collaborate and better coordinate the care of their patients.”
Even at this late stage, however — more than two years after full implementation of the Affordable Care Act, and well into the quality-and outcomes-based health payment reforms mandated by the ACA for Medicare — not enough attention is being given to the potential contributions that community pharmacy can make to reducing the readmission rate for patients transitioning from hospital to home.
“Ineffective care transition processes lead to adverse events and higher hospital readmission rates and costs,” according to a report from the Joint Commission’s Center for Transforming Healthcare. “One study estimated that 80% of serious medical errors involve miscommunication during the hand-off between medical providers.”
However, the commission noted, “readmissions within 30 days of discharge can often be prevented by providing a safe and effective transition of care from the hospital to home or another setting.” And among the collaborative-care activities that can have “very positive effects on transitions,” its report added, is “medication reconciliation, with the involvement of pharmacists.”
NEHI, a national health policy institute, agreed. In a study, the group found that a large percentage of hospital readmissions are caused by medication-related adverse events. “Medication management is at the core of advanced discharge planning and transitional care,” the health policy group reported. “This reflects three realities: adverse events are a major cause of avoidable hospital readmissions; more post-discharge adverse events are related to drugs than other causes; and lack of adherence to medications prescribed at discharge has been shown to be a driver of post-discharge adverse drug [events].”
NEHI urged the creation of integrated, multi-disciplinary healthcare teams — including community pharmacists — to improve post-discharge patients’ health and lower hospitalization costs.
Improved medication adherence reduces hospital readmissions
Much of the flow of patients back into the hospital can be traced to medication nonadherence. “The lack of adherence — not taking medications, not taking the right medications or taking the right medications the wrong way — is esti