Las Vegas—Pharmacists can help reduce hospital readmissions for older patients by participating in a coordinated hospital discharge system and providing medication reconciliation and education, a presenter at the recent Managed Health Care Associates Business Summit meeting said.
Current statistics on readmissions support the need for such improvement programs. Almost one-fifth (19.6%) of Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, according to the speaker Joseph Lewarski, RRT, the vice president of clinical affairs for Invacare Corp., a manufacturer of wheelchairs, respiratory products and other medical equipment. Nearly 27% were readmitted for heart failure (HF) and 23% for chronic obstructive pulmonary disease (COPD).
Hospitals have become increasingly concerned with readmissions, especially as the Centers for Medicare & Medicaid Services is now penalizing them for “preventable readmissions” through its Readmission Reduction Program, which took effect Oct. 1, 2012. Some 2,000 hospitals received some level of penalty for fiscal year 2013, Mr. Lewarski said, and 307 received the maximum 1%.
Although the causes of readmission are complex and not completely understood, in many cases readmission can result from “post-hospitalization syndrome,” a generalized vulnerability to illness, Mr. Lewarski said.
“Spending time in the ICU is like being in a casino in Vegas,” he told Pharmacy Practice News. “There’s lots of noise, lots of people moving around and you can’t tell what time it is. Add to the environment myriad drugs, including sedatives and pain medications, and it’s easy to become disoriented.” Out of routine, older patients can become sleep deprived or develop nutrition issues, lose muscle strength or have exacerbated dementia. “When you put it all together, a sick person may come in for one diagnosis but have other consequences.” Side effects of new drugs may complicate these issues.
Long-term oxygen therapy may improve outcomes and survival among patients with COPD, as well as an HF-associated breathing difficulty called Cheyne-Stokes respiration, according to recent medical studies, he said.
The key components to reducing readmissions for patients with COPD and HF are comprehensive predischarge planning, with attention to seamless transition and continuity of care; and patient education about medications and compliance, daily living skills, transportation and nutritional support, Mr. Lewarski said. Be aware of reductions in vision and hearing when educating older patients, he stressed.
More Discharge Recommendations
Two pharmacy experts not at the meeting gave their own discharge recommendations to Pharmacy Practice News.
There are three key things pharmacists should do before patients are discharged, said Michael “Mick” Murray, PharmD, MPH, a distinguished professor of pharmacy and the endowed chair of medication safety at Purdue University’s College of Pharmacy, West Lafayette, Ind., and the executive director of the Regenstrief Center for Healthcare Effectiveness Research, in Indianapolis. first, he said, tell the patient who you are and why you came to visit: “It sounds obvious, but when you show up on discharge, the patients see so many people they get confused.”
Next, ask the patient how much time he or she has to talk before he or she is being picked up by a family member or taken off for an x-ray or other appointment. That allows you to tailor your instructions to the time allotted. Third, if there’s not a lot of time, ask the patient up front what questions he or she has about medications and address those first. Ask patients how likely it is that they will be able to follow medication instructions at home. This provides a chance to go over medication safety tips that otherwise could be overlooked.
Sean Jeffery, PharmD, a clinical professor at the University of Connecticut School of Pharmacy, Storrs, and a clinical pharmacist in geriatrics for the VA Connecticut Healthcare System, West Haven, said he has been shocked by the number of patients with COPD who don’t know how to use their inhalers: “You cannot assume that because someone has a COPD medicine that they know how to use it or are using it properly.”
It’s crucial to demonstrate how to use inhaled medications and spacers, as needed. “It is challenging to design an inhaler regimen that is simple to use, doesn’t require frequent dosing and doesn’t break the bank,” said Dr. Jeffery. “Each medicine has its own proprietary design.” In some cases, physicians also need to be educated about inhalers and their instructions and limitations, he said.
Medication reconciliation also is important, especially among patients with HF who are taking multiple medications including angiotensin-converting enzyme (ACE) inhibitors, Dr. Jeffery said. If patients with HF transfer from one hospital to another, they may be prescribed a different ACE inhibitor from each pharmacy. “I’ve seen patients on Zestril, lisinopril and Prinivil, not realizing they’re the same thing, and they wonder why their blood pressure is low.”
One pilot program being tested by his VA system to improve patient health and reduce readmissions is shared medical appointments for veterans with diabetes. Six to eight patients with diabetes and a high risk for cardiovascular complications are brought in for quarterly outpatient appointments with a nurse educator, a health psychologist, a dietitian, a physician and a clinical pharmacist with prescriptive authority. Patients receive joint education but individual medication management by the pharmacist. The VA also plans to pair similar patients as “health buddies” to encourage each other to stay healthy, with the goal of improved health outcomes.
“I absolutely think this model could work for HF and COPD patients,” Dr. Jeffery said. “We need to catch COPD patients early, make sure they’re on the right medications, they stop smoking and have training on the use of inhalers, diet and exercise.”
For a resource guide from the VA on shared medical appointments for diabetes patients, see http://www.queri.research.va.gov/tools/diabetes/shared-med-appt.pdf.