imageChicago—Health-system pharmacists have been busy testing ways to reduce preventable medication-related hospital readmissions in anticipation of the Medicare reimbursement penalties that began to hit noncompliant hospitals on Oct. 1 (the start of the 2013 program year). Ultimately, it will be bundles of coordinated interventions across multiple settings, rather than single stand-alone tactics that lead to workable solutions, said Kristine Gullickson, PharmD, FASHP, at the 2012 leadership conference of the American Society of Health-System Pharmacists (ASHP).

At present, “the data are mixed” on how best to tackle one of health care’s most pressing issues, with some interventions showing little effect and others packing more of a wallop, Dr. Gullickson said during a session on care transitions. “We have a lot of work to do, and [pharmacists have] a lot of opportunity to get involved,” added Dr. Gullickson, the director of pharmacy at Abbott Northwestern Hospital, in Minneapolis.

Outcomes data are needed within the profession to prove the value of transitions work, and it remains to be seen whether the data will support the additional pharmacy resources required to do this work well, she said.

Dr. Gullickson cited an analysis of 43 studies that found no single intervention, implemented alone, to be regularly associated with a significant reduction in 30-day rehospitalizations. The study also found, however, that several categories of interventions together appeared to reduce readmissions. Those interventions included predischarge education and medication reconciliation; post-discharge phone calls and home visits; and a coach to help patients bridge transitions between care settings (Ann Intern Med 2011;155:520-528).

A recent survey of 500 hospitals offers some clues on why some efforts to reduce readmissions come up short. The survey looked at 10 practices associated with reduced readmissions among patients with heart failure or acute myocardial infarction. Of the surveyed hospitals, 90% reported having written objectives on reducing readmissions, but only 49.3% partnered with community physicians and only 23.5% partnered with local hospitals to manage these patients. Furthermore, 46.4% of hospitals never involved pharmacists or pharmacy technicians in obtaining medication histories, and only 3.2% and 13.9% made contact with outside pharmacists or primary care providers, respectively, for medication reconciliation (J Am Coll Cardiol 2012; 60:607-614).

With an estimated 50% of patients who leave the hospital experiencing a medication-related issue, “we certainly have opportunities, not only in the hospital, but at discharge as well as when [patients are] at home,” Dr. Gullickson said during her presentation.

In a follow-up interview, Dr. Gullickson noted that the current spotlight on readmissions gives health-system pharmacists an excellent opportunity to advance their practice by using their expertise to address an important problem and affect patient care.

“Make sure your department is riding that wave,” she advised. “Don’t let the opportunity slip by, because we know we can provide value.” Start with a pilot project “and then expand from there,” she said.

Five Successful Interventions

Although definitive solutions to the readmissions quagmire have yet to be teased out, trends are beginning to surface, Dr. Gullickson noted. Of 11 programs in the Medicare Coordinated Care Demonstration, four reduced hospitalizations by 8% to 33% among high-risk patients. At least three of these programs used the following approaches:

  1. frequent face-to-face contact with patients as a supplement to phone calls;
  2. a designated communication hub for providers;
  3. evidence-based patient education;
  4. strong attention to medication management; and
  5. timely, comprehensive transitional care following discharge (Health Aff 2012;31:1156-1166).

“It’s not just one thing that’s going to work … it’s a team approach” and a “package” of interventions with key components, such as a “discharge advocate” and follow up in the ambulatory setting, Dr. Gullickson said.

Research also is helping to identify which patients are most likely to need these interventions, she said. An analysis of adverse drug event (ADE) data revealed that four medications are implicated in 66% of emergency hospitalizations for ADEs: warfarin (33.3%), insulin (13.9%), oral antiplatelets (13.3%) and oral hypoglycemics (10.7%) (N Engl J Med 2011;365:2002-2012).

Such data are “important as we start to talk about risk stratification and which patients should we concentrate on,” Dr. Gullickson said. “Health systems can plan where to focus their efforts by looking at their own data.”

That is where Abbott Northwestern Hospital began when it launched a pilot project to expand the hospital’s care transition efforts from heart failure, acute myocardial infarction and pneumonia to all conditions in 2011. The pilot focused on identifying patients at high risk for readmission based on hospital and emergency department use and other factors, and the development of a transitions care team consisting of a hospitalist, nurse manager, social worker, pharmacist and community pharmacy technician liaison, with a goal to reduce potentially preventable readmissions by 15% in the first year.

A review of system-wide data revealed that 40% of patients returned to the hospital within seven days of discharge, which meant that the team needed to focus on preparing patients for those first critical days after leaving the hospital, Dr. Gullickson said. Not surprisingly, the data indicated that patients going to skilled nursing facilities (SNF) or home care settings were at greater risk for readmission. “We had to work really hard to develop what our plan was to get our patient through that bridge—that first three to five days—and then figure out what structure they had after that,” she said.

Furthermore, an analysis of 180,000 system-wide discharges over two years showed that patients receiving more than 10 outpatient medications were five times more likely to be readmitted. These high-risk patients made up 9% of the inpatient population.

Focusing on High-Risk Patients

The transition team’s intervention “package” for these high-risk patients included a medication history to identify discrepancies and problems; an assessment of the patient’s ability to manage medications; daily rounds by a pharmacy technician to resolve insurance and copay issues and ensure that patients had their discharge medications at discharge; progress notes with recommendations to providers; a standard process for handoff to the next provider; and a transition conference with the patient, family and/or caregiver to set post-discharge goals and address risks and barriers that could lead to rehospitalization.

Pharmacists attended these conferences only for the most complicated cases because patients and families said they were overwhelmed by the number of providers in the room, Dr. Gullickson said. Furthermore, “it takes 30 to 45 minutes a day for those conferences, and we don’t have the resources to commit our staff to attend all of those.”

Inpatient pharmacists spent an average of 50 minutes and made an average of three drug therapy recommendations per patient, with an acceptance rate among providers of 68%. “The reason it wasn’t higher was that many of the interventions … didn’t need to be addressed right away in the hospital” and could be handled by the ambulatory physician, Dr. Gullickson said. The hospital was not able to track follow-up on those recommendations. “That’s still a hole that we need to work through in our system,” she said.

The hospital conducted similar pilots for heart failure and inpatient-to-SNF patients. The heart failure pilot compared a pharmacist review and education at discharge plus a follow-up phone call and a clinic visit with a pharmacist review at the clinic visit only. There were 13.6 interventions per patient in the transitions arm versus 6.9 in the clinic-only arm. In all, 69% of interventions in the clinic-only arm could have been addressed earlier with inpatient pharmacist involvement, reported Dr. Gullickson. Data for the SNF pilot are still pending.

At Sharp Memorial, Tracking From Admission to Discharge

The Continuum of Care Network at Sharp Memorial Hospital, San Diego, one of eight organizations recognized by ASHP for pharmacist innovation in care transitions, focuses on heart failure patients but takes referrals from hospitalists, case managers, social workers and other team members for high-risk patients with all diseases.

The program, a cooperative effort with the Touro University-California College of Pharmacy, in Vallejo, involves a pharmacy postgraduate in work that extends beyond the boundaries of medication reconciliation, drug interactions and dosing, said Julie Truong, PharmD, a Continuum of Care resident pharmacist.

Dr. Truong monitors patients on a daily basis from admission to discharge, looking at renal function, laboratory results, microbiology changes and other variables, and working closely with the entire care team to “anticipate discharge medications. It’s not just dropping in here and there, it’s really the entire process that I take responsibility for,” including making sure patients are able to pick up their medications at the community pharmacy. That comprehensive involvement “really broadens the pharmacist’s role,” she said.

In the program’s first several months, resident pharmacist Andrea Backes, PharmD, focused on medication reconciliation at discharge and follow-up home visits five days post-discharge. Although discharge is where many medication problems eventually surface, “I noticed that a lot of problems happen at the forefront—at the admissions side,” Dr. Truong said. She said that monitoring patients starting at admission helps to nip those problems in the bud.

“Ideally we’d love to have [a pharmacist] who could work admissions, discharge and at home, but we had to ‘pick our battles,’ ” added Albert Rizos, PharmD, a system senior clinical pharmacy specialist at Touro. With Dr. Backes’ discharge and home-visit work and Dr. Truong’s current admission-through-discharge focus, “we’re getting extremely valuable data across all three,” and hopefully, those data ultimately will be used to demonstrate the value of these interventions and support the addition of pharmacy resources, he said.

To date, the two residents have tracked interventions on 466 patients. The heart failure core measure compliance rate, which was in the 85th percentile at baseline, has risen to the 97th percentile with the pharmacist intervention, said Dr. Rizos. Outcomes data will be available next year.