Hollywood, Fla.—To mitigate the long-anticipated Medicare penalties for excessive hospital readmissions that took effect in October, hospitals nationwide have struggled to shave their readmission rates and avoid potentially severe financial harm. Because medication-related factors are thought to play a major role in readmissions, pharmacists have seen an opening to contribute to the cause.
Three studies presented at the American College of Clinical Pharmacy annual meeting assessed the impact of those contributions. The initiatives studied focused on resolving drug-related patient care issues that often arise during the transition of care between inpatient and outpatient settings.
In one pilot study, researchers developed a protocol in which inpatient pharmacists continued their contact with patients after discharge from a general medicine unit, allowing them the opportunity to solve medication problems both during and after hospitalization. “The inpatient pharmacist who took care of a hospitalized patient was the same one who followed up after discharge. I think that was the real key to the program’s success,” said lead co-author Kim Coley, PharmD, FCCP, a professor of pharmacy and therapeutics at the University of Pittsburgh School of Pharmacy.
The pharmacists conducted medication reconciliation at admission and discharge, assessed patient access to medications and adherence to his or her regimen, provided patient education and called the patient within 72 hours of discharge to resolve any lingering issues. Because the protocol was standardized, every pharmacist in the study followed the same procedures throughout the transition process.
The model also pushed pharmacists beyond their comfort zones, Dr. Coley noted. For instance, they spent more time in direct patient care activities and less time making rounds with the care team. “They liked this change, because they actually saw the impact their actions had on patients,” she said.
Another novel aspect of the program was that inpatient pharmacists updated the outpatient medication list in the medical record. “That was a big change and something our hospital pharmacists had never done before,” said Dr. Coley. “It allowed everyone to be on the same page and improve continuity of care after a patient was discharged.”
Overall, 220 patients participated in the study. Pharmacists resolved a mean of 3.5 medication discrepancies per patient at the time of hospital admission, and 7.9 discrepancies per patient when they compared the discharge medication list with the outpatient medical record. After discharge, the pharmacists reached 72% of eligible patients (n=112) via follow-up phone calls.
The 30-day readmission rate among patients enrolled in the study was 11%, compared with 24% for a matched control group. Among patients on this unit, scores on the Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) survey for how well patients were taught about the uses and side effects of their medications rose from 22% and 27%, respectively, to 75%.
Complex-Return-Continuity System Eases Care Transitions
In another pilot program, researchers implemented a system that they called complex-return-continuity (CRC), in which patients were booked for a post-hospitalization appointment to see several clinicians in sequence.
First, a patient met with a clinical pharmacist for medication reconciliation and a thorough assessment of their medication regimen, and to identify medication discrepancies, explained co-author Gretchen Tong, PharmD, CPP, a clinical instructor in the University of North Carolina Department of Family Medicine, in Chapel Hill. The pharmacist then consulted with the patient’s primary care provider (PCP) to relay pertinent findings and recommendations, after which the PCP met with the patient. “This way, the pharmacist can focus on medication therapy and allow the primary care provider to focus on the rest of the patient’s medical care,” Dr. Tong said. If needed, the patient met with a social worker to coordinate additional care and address issues such as community resource needs or financial barriers.
Thirty-six patients were scheduled for the CRC visit and 28 attended. The hospital readmission rate for no-shows was 27.3%, compared with 16.7% for patients who kept their appointments. According to survey results, most patients and providers perceived that patients had an improved understanding of their medications after the multidisciplinary visit. CRC appointments lasted about a third longer than typical, single-provider visits (90 vs. 67 minutes, on average), but patients reported that they did not perceive
Dr. Tong acknowledged that the study’s small size prevented the researchers from making firm conclusions about the program’s long-term efficacy. “We have shown proof of concept by evaluating implementation and process measures,” she added. “We still need to evaluate clinical outcomes of this interdisciplinary approach, and we’re in the process of designing a larger study to evaluate that.”
REACH Program Improves Medication Management
A third study evaluated the Medication REACH program, which was implemented to increase pharmacist engagement during the hospital discharge process, and thereby improve medication management among high-risk patients with acute myocardial infarction (AMI), congestive heart failure (CHF) and hypertension. (The program takes its name from “validate medication Reconciliation; deliver patient-centered Education; resolve medication Access issues during transition; coordinate a comprehensive Counseling approach; Healthy, compliant patient at home.)
Eighty-nine patients (17% with AMI, 48% with CHF and 82% with hypertension) were randomized to receive either traditional nurse-mediated or clinical pharmacist–mediated discharge counseling under REACH. Four clinical pharmacists were directly involved in medication reconciliation, patient education, resolving medication access issues and conducting medication counseling phone calls after discharge. During these phone calls, pharmacists reviewed medication regimens, resolved outstanding issues and underscored the importance of medication adherence.
Patients in the intervention group (n=47) were less likely than those in the control group (n=42) to be readmitted to the hospital within 30 days (10.6% vs. 21.4%, respectively). Clinical pharmacists made 59 medication management interventions, the most common being the initiation of a medication therapy (25%).
The hospital considered the program a success, so they terminated the REACH study and opened the program to all patients who needed it, said co-author Deborah Hauser, RPh, MHA, the network pharmacy director at Einstein Healthcare Network, in Philadelphia. “There are so many people who needed this type of intervention that the hospital wanted the study to end so that REACH could serve more patients,” she added. However, because the study was concluded prematurely, not enough data had been gathered to allow statistical analysis.
The take-home message from these studies is that pharmacists are stepping up and asserting that these activities are within their scope of practice, commented Jeannell Mansur, RPh, PharmD, FASHP, a practice leader in medication safety with the Joint Commission. “They believe they can have a positive impact. It’s important to have pilot studies like these to test models and have pharmacists dedicated to them. It will be interesting to see how hospitals can find the resources for programs like these once they expand to cover many more patients. Staffing for pilot projects is always much simpler than when programs are rolled out on a larger scale.”