Reducing Hospital Readmissions: A New Opportunity for Community Pharmacists

According to the Centers for Medicare & Medicaid Services (CMS), about 1 in 5 patients receiving Medicare who are discharged from a hospital are readmitted within 30 days.¹ A portion of these readmissions are believed to be preventable, although estimates vary widely. An analysis of 2005 Medicare claims data by the MedPAC (Medicare Payment Advisory Commission) concluded that about three quarters of readmissions within 30 days were potentially preventable, representing an estimated
$12 billion in Medicare spending.¹

Hospitals have implemented numerous strategies to reduce preventable readmissions, including better preparing patients for discharge, improving patient education about home medications, and improving communication about care transitions. Some interventions have shown improvements, but the changes have been slow and the results have been variable. Despite these efforts, between 2008 and 2010 there was little change in the 30-day readmission rate for 3 conditions (Table).



Pursuant to provisions in the Affordable Care Act, CMS has identified avoidable readmissions as 1 of the leading problems facing the US healthcare system. Congestive heart failure, acute myocardial infarction, and pneumonia were identified as the top 3 diagnoses contributing to readmissions.²

In 2012, CMS began to penalize hospitals with high rates of readmissions related to these 3 conditions. The penalty is calculated using a complex formula based on the amount of Medicare payments received by the hospital for the excess readmissions. The penalty cap is set at 1% of payments for the first year, 2% for the second year, and 3% for each year thereafter.

For the first 2 years (fiscal years 2013 and 2014), the penalty applies to readmissions of Medicare patients aged 65 years and older with diagnoses of congestive heart failure, acute myocardial infarction, or pneumonia. In 2015, these will be expanded to include patients who are admitted for acute exacerbation of chronic obstructive pulmonary disease, as well as for patients admitted for elective total hip and knee replacements.³ In an effort to increase transparency, there are also public reporting requirements that will make this information available to health plans and patients.

Hospitals, health plans, and quality improvement organizations have all implemented programs that have successfully reduced hospital readmissions. There seems to be general agreement that there is a significant op­portunity to reduce readmissions and realize a positive return on investment by integrating pharmacist services into the care-transition process. Historically, however, financial incentives have not provided payment for these services. As payment models, such as shared savings programs associated with accountable care organizations (ACOs) evolve, there are new opportunities for pharmacists to contribute to improved patient care and reduced costs. Some key points to consider are:

• Medication adherence is an important factor in the management of chronic disease, and a significant number of patients do not adhere to the medication regimens they are prescribed
  
• There are many effective traditional and evolving roles of pharmacists in medication management supported by published results, including medication reconciliation, discharge counseling services, medication therapy management/adherence, and patient self-management programs
  
• A variety of successful care transition models exist, and several published models have included pharmacists. The models that have included pharmacists have generally had an impact on decreased hospital admissions, readmissions, and emergency department visits^4-7
  
• There is some potential benefit to establishing innovative care transition models that include both hospital- and community-based pharmacists.

In 2010, America’s Health Insurance Plans published a report that described several new programs that health plans have implemented to address problems with readmissions, particularly for patients with chronic diseases.⁸ Several of the successful programs described the integration of pharmacists, and 1 key trend that was noted was that the pharmacists’ role was becoming even more important as time goes on.

In some cases, it may be more desirable and profitable for a hospital or an ACO to invest in their own pharmacy resources to develop similar readmission prevention programs that would be staffed with an ambulatory care pharmacist who could coordinate that part of care with discharge planning and home care nurses. However, in a recent article published in Health Affairs, Smith and colleagues describe a pharmacy network model where “a pharmacist or group of pharmacists [is] contracted by the ACO or payer to provide medication management services for specific patients. A contracted pharmacist may meet with a patient in person in the medical home, a community pharmacy, or the patient’s home or via an interactive video connection, depending on the complexity of the patient’s drug regimen and the intensity of pharmacist services required.”⁹ It would seem that this vision supports an expanded role for community pharmacists in new models of care and care transitions.

Examples of community pharmacists collaborating with healthcare organizations and health plans are becoming more common; for example, Walgreens offers its WellTransitions program. The program offers a prescription review process, bedside medication delivery, a follow-up phone call within 9 days of discharge, and outcomes reporting.

Early results indicate that WellTransitions has been effective. Walgreens reports that, within the first 6 months of the program’s implementation at 5 hospitals, patients had a 9.4% unadjusted rate of 30-day readmission, compared with a 14.3% 30-day readmission rate for patients eligible for but not participating in the program.¹⁰

CVS Caremark also offers an integrated readmission prevention program for its members in partnership with Dovetail Health, a healthcare management company based in Massachusetts. The group recently contracted with Aetna for these services.^11,12

One advantage of these types of partnerships is that they provide a broad reach and the ability to manage large numbers of patients. A limitation of health plan partnerships is that services will be limited to only those patients covered under the plan.

The “bedside pharmacy” program implemented at the Western Maryland Health System in collaboration with PharmaCare, a local retail pharmacy chain, is an example of a hospital organization and community pharmacy collaboration.¹³ The focus of the program is on educating patients at discharge about the importance of medication adherence. The pharmacist visits patients in their rooms—thus coining the new term “bedside pharmacy”—and checks each patient’s chart to review key information and reconcile home and hospital medications. The pharmacist counsels each patient about their medication regimen and contacts the patients after discharge. Patients are also given the option to receive their discharge medications from PharmaCare or from another pharmacy. Results have thus far been positive; readmissions decreased 28% in the first year of the program. Also, patient satisfaction results with discharge instructions improved from about 65% to more than 90%.

There are other examples of independent pharmacies partnering with hospitals to address the problem of readmissions. Grove City Medical Center, a small community hospital in Grove City, PA, has created a “Home with Meds” program that provides patients with a 1-month supply of medications at discharge, with their local pharmacist following up. Of note, the hospital met the standard for readmissions and did not see any readmission penalties in 2013.¹⁴

It is anticipated that these models will continue to grow and evolve, and the financial incentives are beginning to align to support the expansion of partnerships between community pharmacists, healthcare organizations, and health plans. While not necessarily designed to address readmissions alone, 16 of 107 CMS Health Care Innovation Awards include mention of a role for pharmacists; 2 specify collaborations with community pharmacists.¹⁵

The Pharmacy Society of Wisconsin received an award that expands the successful Wisconsin Pharmacy Quality Collaborative. Participating pharmacists will work collaboratively with physicians and other prescribers to target patients with diabetes, chronic heart failure, asthma, and geriatric syndromes. Regional implementation specialists and clinical pharmacists will train community pharmacists across the state. The results of this and other innovations will hopefully support continued expansion of pharmacist integration into new care and payment models.

Under current payment models, making the business case for community pharmacist involvement is challenging. There are opportunities to collaborate with a local hospital or health system, existing pharmacy network, pharmacy schools, and health plans that may be willing to outsource versus hiring additional staff to provide pharmacy care transition services. Existing programs primarily include a fee-for-service model or increasing prescription volume by including a discharge prescription counseling and delivery service.

Conclusion

The current focus on improved care transitions and readmission reduction efforts offers an opportunity to develop or expand community pharmacist services. Pharmacists should seek opportunities for collaboration with health plans and provider organizations and develop programs to reduce readmissions and improve quality of care.

References

1. Health Affairs. Health Policy Briefs: Medicare Hospital Readmissions Reduction Program. November 12, 2013. www.healthaffairs.org/healthpolicybriefs/brief.php? brief_id=102. Accessed December 17, 2013.
   
2. Goodman DC, Fisher ES, Chang C-H. The Revolving Door: A Report on Hospital Readmissions. Robert Wood Johnson Foundation; February 2013. www.rwjf.org/
   content/dam/farm/reports/reports/2013/rwjf404178. Accessed December 17, 2013.
   
3. Centers for Medicare & Medicaid Services. Readmissions Reduction Program. August 2013. www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Acute InpatientPPS/Readmissions-Reduction-Program.html. Accessed December 17, 2013.
   
4. Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-187.
   
5. Al-Rashed SA, Wright DJ, Roebuck N, et al. The value of inpatient pharmaceutical counseling to elderly patients prior to discharge. Br J Clin Pharmacol. 2002;54:657-664.
   
6. Stewart S, Pearson S, Horowitz JD, et al. Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care. Arch Intern Med. 1998;158:1067-1072.
   
7. Walker PC, Bernstein SJ, Jones JN, et al. Impact of a pharmacist-facilitated hospital discharge program; a quasi-experimental study. Arch Intern Med. 2009;169:2003-2010.
   
8. America’s Health Insurance Plans Center for Policy and Research. Innovations in Reducing Preventable Hospital Admissions, Readmissions, and Emergency Room Use: An Update on Health Plan Initiatives to Address National Health Care Priorities. June 2010. www.ahip.org/uploadedFiles/Content/Departments/Policy_and_Research/Innovations_Report_Series/Innovations-2010-Report.pdf. Accessed December 17, 2013.
   
9. Smith M, Bates DW, Bodenheimer TS. Pharmacists belong in accountable care organizations and integrated care teams. Health Aff (Millwood). 2013;32:1963-1970.
   
10. Walgreens. Services for Businesses. www.walgreens.com/healthcare/business/ProductOffering.jsp?id=wellTransitions. Accessed December 17, 2013.
    
11. Aetna collaborates with CVS Caremark and Dovetail health to help members manage their prescriptions [press release]. Needham, MA: Dovetail Health; August 22, 2013. www.dovetailhealth.com/newsroom/articles-and-press-releases/bid/70432/Aetna-Collaborates-With-CVS-Caremark-and-Dovetail-Health-to-help-members-manage-their-prescriptions. Accessed December 17, 2013.
    
12. Dovetail Health. Dovetail Programs/Transition Management. www.dovetail health.com/our-programs/transition-management/. Accessed December 17, 2013.
    
13. Balch J, Pirolozzi J. Community and Hospital Pharmacy Collaborate to Reduce Readmissions. Dublin, OH: Cardinal Health. www.cardinalhealth.com/us/en/
    essential-insights/best-practices/community-hospital-pharmacy. Accessed December 17, 2013.
    
14. Twedt S. Few hospitals meet standards for reducing readmissions. Pittsburgh Post Gazette. January 18, 2013. www.post-gazette.com/businessnews/2013/01/18/
    Few-hospitals-meet-standards-for-reducing-readmissions/stories/201301180196. Accessed December 17, 2013.
    
15. American Pharmacists Association. Pharmacy well represented in Innovation Center awards. Pharmacy Today. July 2012. www.pharmacist.com/node/28185. Accessed December 17, 2013.