Health care is in the midst of a transformation in which health care providers are increasingly being paid for value provided rather than per service.
Health care is in the midst of a transformation in which health care providers are increasingly being paid for value provided rather than per service. Moreover, the payment implications of hospital readmissions are a major challenge facing hospitals and health systems in this changing landscape. With the advent of the Patient Protection and Affordable Care Act (ACA), hospital readmissions are at the forefront of “crises” demanding meaningful (and efficient) solutions.
The Hospital Readmissions Reduction Program was established with the passage of the ACA.1 Beginning October 1, 2012, this program has monitored hospital discharges for 3 distinct conditions: acute myocardial infarction, heart failure, and pneumonia. In fiscal year 2015, chronic obstructive pulmonary disease, total knee arthroplasty, and total hip arthroplasty were added to the list of applicable conditions. Readmission to a hospital within 30 days of discharge for one of the above conditions counts toward the hospital’s readmission ratio, with those hospitals that have a readmission ratio that exceeds an expected value being penalized with reduced payments. A graded approach to penalizing hospitals for excess readmissions was phased in over a period of 3 years. Beginning in 2012, hospitals with excess readmissions were at risk for up to a 1% reduction in total base operating diagnosis-related group payments. This reduction was increased to a maximum of 3% in 2015.1
Fortunately, hospitals and health systems have begun to implement effective programs for reducing readmissions. Pharmacists are uniquely positioned to meaningfully impact patient readmissions. As the medication expert on the health care team, pharmacists can optimize medication use, reduce overall costs, and ultimately improve patient outcomes through effective medication management.2 Moreover, pharmacists in the ambulatory care environment are positioned to manage medication therapy in a way that has a great impact on the patients and populations they serve, and they have the potential to help ease the strain of increased demand by an aging patient population.3 The diverse skill sets and unique perspective of pharmacists make them a valuable asset to any team trying to solve the “readmissions crisis.”
Effectively reducing readmissions is contingent on a continuing focus on effective transitions of care (TOC). Patients across the entire continuum of care are vulnerable to the gaps in communication that can occur when transitioning from one setting to the next, putting the patient at greater risk for readmission. Because transitions of care occur across the entire continuum of care, opportunity to improve TOC and meaningfully reduce readmission rates exists in multiple settings. Both acute care and ambulatory care practitioners have demonstrated successful models for reducing readmissions by focusing on improving transitions. Looking ahead, readmission reduction models that focus on individual patients will remain important, and population health strategies will grow in importance as payers strive to reduce costs and improve care. The remainder of this article discusses strategies that pharmacists have successfully used to meaningfully impact their hospital’s or health system’s readmissions from both the acute and ambulatory care settings.
Acute care pharmacists have reported several successful strategies for reducing readmissions at their hospitals and health systems.4-7 Many of the successful strategies for reducing readmissions incorporate a core set of effective practices for improving the transition of care and reducing readmissions. Effective practices include multidisciplinary involvement,4 medication reconciliation at admission and discharge,5 pharmacist- provided medication counseling,4,5,7 bedside delivery of medications,6 and post-discharge follow-up phone calls.4-6
A study by Warden and colleagues highlights the effects of pharmacistprovided medication reconciliation and patient education.5 In this study, the pharmacist was responsible for obtaining a medication history, completing admission and discharge medication reconciliation, providing recommendations for optimization of heart failure medication therapy, and providing both disease and medication education. Additionally, the pharmacist conducted postdischarge phone calls at 14 and 30 days. Following this intervention, 30-day all-cause readmissions were significantly reduced in the intervention group (17%- 38%; P = .02). This study very effectively shows how a comprehensive approach to improving the transition from hospital to home can have a far-reaching effect on readmission rates.
Large patient volumes and limited pharmacist time often complicate plans for involving pharmacists in the discharge process. For these reasons, it is important to triage and prioritize patients with the highest risk for readmission. Pal and colleagues reported on pharmacist- provided discharge medication reconciliation and counseling for patients prioritized by a screening tool that included the total number of discharge medications as well as the presence of “problem medications” as defined by Project BOOST (Better Outcomes by Optimizing Safe Transitions).8 In this study, those patients reviewed by a pharmacist experienced a lower 30-day readmission rate compared with the usual care (16.8% vs 26.0%; OR 0.572; 95% CI, 0.387- 0.852). This study also demonstrated that patients with a higher number of discharge medications had higher 30-day readmission rates. Thus, it is reasonable for pharmacists to consider targeted approaches for meaningfully impacting readmission rates in their hospitals.
Ambulatory care pharmacists have also reduced hospital readmissions. For example, Cavanaugh and colleagues implemented a multidisciplinary readmission prevention program at the University of North Carolina Internal Medicine Clinic (UNC IMC).9 The UNC IMC posthospital discharge clinic saw eligible UNC IMC patients discharged from UNC Hospitals within 5 calendar days of hospital discharge. A clinical pharmacist practitioner (CPP) in the clinic coordinated the 60-minute appointment, which included a 20-minute attending physician appointment embedded within the 60-minute clinic visit. The CPP’s focus extended beyond medications to all key visit components. (CPPs are licensed, advanced practice providers in the state of North Carolina who practice under a collaborative practice agreement with a physician.) This study evaluated the effectiveness of their clinic using a retrospective cohort approach, matching patients who were not seen in the post-hospital discharge clinic with those who were seen in the clinic. Patients seen in the post-hospital discharge clinic with a pharmacist experienced significantly fewer readmissions at 30-days and 90-days compared with the usual care group (HR at 30 days, 0.32; 95% CI, 0.12-0.91; HR at 90 days, 0.34; 95% CI, 0.16-0.72). This study highlights the important role of ambulatory care pharmacists working with multidisciplinary teams in preventing readmission.
Tips for Being Successful
The studies referenced above demonstrate the impact pharmacists can have in hospital and health system efforts to meaningfully impact readmission rates. The following are strategic tips that pharmacists can implement in order to promote effective transitions in care that result in reduced readmissions:
Effective hospital readmissions reduction efforts are centered on ensuring safe transitions of care. By allocating pharmacists to both the acute care and ambulatory care settings and implementing the tips provided above, health systems can effectively address the readmissions crisis and provide better care to the patients they serve.
David A. South, PharmD, is a PGY-2 healthsystem pharmacy administration resident at University of North Carolina Hospitals and Clinics in Chapel Hill, North Carolina, and an MS candidate at UNC Eshelman School of Pharmacy.Lindsey B. Amerine, PharmD, MS, BCPS, is assistant director of pharmacy, University of North Carolina Medical Center, and assistant professor of clinical education, UNC Eshelman School of Pharmacy.