Big transitions in care — next wave in the health reform revolution
Consider this: 1-in-5 hospital patients end 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.
With better systems 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 — the vast majority of those readmissions could be avoided, Jencks and other health experts said.
Strategies to keep patients out of the hospital “will include not only hospitals, but also practitioners and other providers, as well as patient/ family education, support and empowerment,” Jencks said.
Even at this late stage, however — nearly 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.
Many of those patients are in relatively fragile condition. But thus far, Jencks said, payment reforms that “reward low re-hospitalization rates or penalize high rates” are “generally directed at hospitals” through such quality ratings metrics as the Medicare Star Ratings system. This, despite the fact that “other providers and practitioners are vital” in the campaign to reduce readmission rates.
Curbing hospital costs through medication management
It’s no secret that “high-cost hospital care ... is a major driver of national health expenditures,” said Karen Utterback, VP strategy and business development at McKesson’s Extended Care Solutions Group. In a September report, Utterback said getting and keeping patients out of hospitals and back into the home care setting is a critical ingredient in the urgent national campaign for cost-containment.
“If you want to tame national health expenditures, ... you must lower inpatient hospitalization rates, and one of the best ways to do that is through expanded use of home care services,” she wrote. “Home care can be the alternative care delivery model that can have the biggest impact on health spending by reducing the instances and costs of inpatient hospitalization.”
The high cost of hospital readmissions has become a hot-button issue for health reform advocates. “Ineffective care transition processes lead to adverse events and higher hospital readmission rates and costs,” the Joint Commission’s Center for Transforming Healthcare noted in a report. “One study estimated that 80% of serious medical errors involve miscommunication during the hand-off between medical providers.”
However, noted the Joint Commission, “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 a “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, multidisciplinary healthcare teams — including community pharmacists — to improve post-discharge patients’ health and lower hospitalization costs.
Focusing pharmacy on 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 estimated to be the cause of nearly one-third of readmissions of patients with chronic medical illnesses,” Utterback noted.
It’s a problem that goes right to the heart of community pharmacy’s core competencies. Boosting adherence levels among post-discharge patients is an increasingly critical focus for pharmacy providers, particularly those that are allying with hospital systems to reduce readmissions and extend the continuum of care back into the community and the patient home.
Chain and independent pharmacies around the country are stepping up efforts to partner with local hospital groups and health systems in a massive campaign to create a long-term, post-discharge safety net for patients after their release from the hospital. Such national pharmacy providers as Walgreens, CVS Caremark, Rite Aid and Walmart all have long-term initiatives in place to align with hospital systems and help patients transition back into the community, as do such regional players as Thrifty White and Hy-Vee.
Walgreens’ WellTransitions program, launched in 2012 in partnership with local hospital systems in several markets, has shown solid results, yielding a 46% reduction in unplanned hospital readmissions within 30 days of discharge for patients who were part of an outcomes study, according to the company. And Rite Aid has grown its Health Alliance transition-of-care partnership to some 60 of its pharmacies in collaboration with seven health systems around the United States. The program is reducing readmissions and improving patient outcomes through close collaboration with post-discharge patients and their physicians, said a Rite Aid official, and through a careful tracking of all pharmacist-patient interactions and results. With support from their wholesaler partners, many independents also are forming post-discharge patient-care networks.
Community pharmacy, said NACDS Foundation president Kathleen Jaeger, has an important role to play “in helping patients to avoid hospital readmissions and adverse events post-discharge.”
The NACDS Foundation in 2014 awarded $1.8 million in research grants to study the impact of pharmacists’ collaboration with patients following their discharge from hospitals. The two-year research effort centers on three ongoing studies:
A collaboration between Walgreens and the University of Mississippi’s School of Pharmacy and Medical Center to examine the impact of pharmacist-provided medication management on hospital