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February 2017, Vol 5, No 2 - Inside Pharmacy
Todd Brown, MHP, RPh
Ester Lee, PharmD candidate
Lisa Li , PharmD candidate
Inside Pharmacy Improving Transition of Care: Opportunities for Community Pharmacists By Ester Lee, PharmD candidate, Lisa Li, PharmD candidate, and Todd Brown, MHP, RPh Ms Lee is a PharmD candidate; Ms Li is a PharmD candidate; and Mr Brown is Vice Chair, Department of Pharmacy and Health Systems Sciences, Northeastern University School of Pharmacy, Boston, MA.

Transition of care is the transfer of the care of a patient from one setting to another.1 In the United States, approximately 20% of 30-day hospital readmissions occur because of uncoordinated transition of care.1-3 Billions of dollars are spent unnecessarily because patients are not receiving proper, coordinated, and consistent care when they are discharged from the hospital into their communities.4 In fact, Medicare reports show that more than $17 billion are spent annually on preventable readmissions; a large percentage of patients are readmitted because of improper medication use after discharge.4 A systematic review showed that up to 2% of medication discrepancies are life-threatening and lead to death.5

Medication discrepancies often occur when patients lack understanding of discharge medication plans, have inadequate literacy to understand the discharge instructions, become nonadherent to a medication regimen, and/or experience adverse drug events.6,7 Expanding community pharmacists’ involvement in postdischarge transition of care and improving communication will benefit patients, healthcare providers, and the healthcare system by decreasing hospital readmissions, medication-related adverse events, and financial burdens. This article reviews the current literature and proposes procedures for transition of care for community pharmacies.

Pharmacist Involvement in Transition of Care

Currently, care transition interventions are often implemented in hospitals when patients are discharged; nevertheless, the care is often not followed on or continued in the community pharmacies.1 The role of the pharmacist has been valuable and critical in discharge medication reconciliation, patient counseling, and postdischarge follow-up plans, in terms of better quality care, as well as financial interest and patient safety.3-5 A recent study showed that implementing medication therapy assessment and reconciliation led by hospital pharmacists before patient discharge resulted in decreased 30-day readmission rates.8 The same study also reported that for every 100 patients receiving medication reconciliation, the intervention resulted in $35,000 of savings, which can lead to an annual savings of at least $1.5 million.8

Although there have been improvements in overall quality and outcomes in care transitions since introducing pharmacists to the process, transition of care notably lacks interventions that enable collaboration with, or incorporation of, community pharmacists. The failure to communicate care from the hospital to the community pharmacy may be a consequence of insufficient understanding of community pharmacists’ qualifications by other healthcare professionals, insurers, patients, and caregivers, thereby preventing community pharmacists from maximizing their abilities and services.9 Other factors could include a lack of information from information technology systems, lack of reimbursement for transition of care services, and patient uptake.

Transition of Care in the Community Pharmacy

Studies have suggested implementing medication therapy management (MTM), a series of healthcare services performed by pharmacists to maximize patient outcomes, in a timely manner in community pharmacies.10-13 With more community pharmacies offering MTM services, research shows the positive effects that community pharmacists can have on medication-related problems during the transition of care.9,14

A few transition of care programs have been developed and introduced in several community pharmacies. Some independent pharmacies have been increasing additional services, such as MTM, home delivery, and vaccinations, with the belief that demonstrating consistent clinical care will gain the attention of the payers, providers, and healthcare systems.9,12

Walgreens implemented its WellTransitions program (which offers services that include bedside medication delivery and follow-up phone calls in the 9 days postdischarge) in 5 hospitals, and showed a decrease in 30-day readmission rates from 14.3% to 9.4% within 6 months.15 CVS Caremark also partnered with Dovetail Health, Needham, MA, and Aetna to offer transitional care services for its members to reduce preventable readmissions.15

The Western Maryland Health System, Cumberland, and a local retail pharmacy, PharmaCare, created a partnership to help patients better comprehend their discharge medications.4 After 1 year, this partnership demonstrated a 28% decrease in readmission rates.4 In addition, according to a recent study by the CVS Health Research Institute, pharmacist-led consultations during transitional care decreased overall 30-day readmission rates, as well as produced a total savings of more than $1300 per member covered by a health plan, regardless of the insurance provider.16 These results provide insight, and show opportunities for third-party payers to consider adopting certain transition of care interventions offered by community pharmacists. However, many of the studies conducted in the community pharmacy settings are narrow, and are restricted to particular hospital–local pharmacy relationships.

Barriers

Despite having community pharmacists readily accessible, many roadblocks discourage care transition services in community pharmacies. A study published in 2015 assessed community pharmacists’ readiness to participate in care transition.17 The primary barrier was the lack of time to offer transition of care services in the community.17 The inadequate staffing of pharmacists and technicians prohibits the incorporation of other services, and prohibits pharmacists from providing efficient and/or sufficient care to patients.9,12,15,17

Other obstacles include poor communication between the physicians and pharmacists, and lack of access to the patient’s hospitalization data.2,10-14,17 Lack of physician and patient acceptance and lack of reimbursements are also reasons why community pharmacists are hesitant to be more involved in transition of care.9,13,14,17 By failing to take a larger role and actively get involved in transition of care, pharmacists may leave patients unaware of the services that community pharmacists are capable of providing.

The American Pharmacists Association has been advocating for the Medicare Part D prescription plan benefit to be included in accountable care organizations (ACOs).10 However, pharmacists still lack the provider status under Medicare, which limits reimbursement opportunities for the services pharmacists provide to patients.10,13,14 Walgreens, one of the first retail pharmacies to establish relationships with ACOs, ended 2 of its 3 ACO contracts in 2014.10 Conflicts emerged because of the inability to exchange information, poor financial return, and low physician participation. Restricted access to health information technology and electronic health records also puts a strain on the efficient integration of community pharmacist participation in ACOs.10

Once pharmacies are able to get reimbursed for their services, it is likely that more community pharmacies will obtain sufficient resources, including time, and be willing to offer these services.

Proposed Transition of Care Procedures for Community Pharmacists

Before any new transition of care services can be offered in community pharmacies, pharmacies would first need to have affiliations with hospitals and insurance companies. Affiliations between hospitals and community pharmacies would be established based on the hospital’s patient population. Pharmacies closest to where the majority of a hospital’s patients reside would be preferred locations for partnerships. Once collaborative relationships are established, patients could access pharmacy information through pamphlets, websites, and other sources used by hospitals and health insurance companies.

We propose the following patient requirements to qualify for the transition of care services. Most sources examine a 30-day time frame when measuring readmission rates because the Centers for Medicare & Medicaid Services imposes financial penalties on hospitals with high 30-day readmission rates, and for readmission of patients who have been discharged for certain diagnoses.1,2,6,12 Therefore, our proposed transition of care services would be offered to patients discharged from hospitals within the past 30 days. Other restrictions may be in place, such as the number of medications or comorbid conditions, for patients to qualify for the services. Studies have identified the most critical time for follow-up as being within 72 hours of discharge.12

To increase the rate of successful transitions, patients should be required to contact a pharmacy that offers transition of care services within 3 days of discharge to qualify for transition of care management services. Additional requirements may include a minimum number of hospital admission days, identifying severity or intensity of disease states, and other risk factors for readmission.

We propose the following strategies for transition of care services, and suggested steps for the process:

  1. Patients will be required to bring their discharge notes, list of home medications, and phone numbers of their pharmacies and primary care providers to facilitate the visit
  2. If the patient did not retain the discharge notes, the pharmacy would request them, and any other necessary documents from the hospital
  3. During the initial visit, pharmacists would provide a complete medication overview of pre- and postdischarge medications to identify any medication discrepancy and redundancy, and address any safety concerns
  4. After the medication overview, pharmacists would educate patients regarding proper medication use, and emphasize the importance of adherence
  5. Patients will receive written instructions on their medication strategy plan to refer back to, and the patients’ primary care providers will be informed of the patients’ current medical condition and any medication changes
  6. After the initial contact with the patient, follow-up would be performed face-to-face or over the phone. Follow-up visits will assess the patient’s medication adherence, medication therapeutic effects, medication-related adverse events, and patient concerns.

Depending on the patients’ needs, they may require ≥1 contacts with a pharmacist for safe and successful care transitions. Because complex medication regimens, multiple medications, and various medical conditions may be difficult to review solely over the phone, ≥1 face-to-face interactions are recommended. However, the CVS Health Research Institute reported that the rates of readmission and cost reductions were similar between in-person and over-the-phone consultations.16 Therefore, patients may have the option of participating only in over-the-phone consultations if geographic or immobility issues are present.

Conclusion

A poor transition of care process has been associated with high readmission rates, preventable healthcare costs, and patient harm, including death. Community pharmacists are often underutilized in the transition of care. The advantages of involving community pharmacists in the care transition are timely transitional care management, and reduced financial burden for the healthcare system and for patients. Although this may reduce the hospital census, more appropriate care could lead to higher reimbursement rates so that the financial impact is minimized. This proposed intervention is an opportunity for community pharmacists to show the financial benefits and improved patient outcomes that they can produce, thereby increasing recognition of the services they have to offer. Payment for these services can come from a variety of sources, including hospitals, insurers, patient-centered medical homes, and ACOs.

References

  1. Kristeller J. Transition of care: pharmacist help needed. Hosp Pharm. 2014;49:215-216.
  2. Reuben DB, Tinetti ME. The hospital-dependent patient. N Engl J Med. 2014;370:694-697.
  3. Weiss D. The role of hospital pharmacists in transitions of care. January 16, 2013. www.pharmacytimes.com/news/the-role-of-hospital-pharmacists-in-transitions-of-care. Accessed January 5, 2017.
  4. Balch J. Community and hospital pharmacy collaborate to reduce readmissions. July 1, 2013. www.cardinalhealth.com/en/thought-leadership/retail-hospital-collaboration.html. Accessed January 5, 2017.
  5. Mekonnen AB, McLachlan AJ, Brien JA. Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis. J Clin Pharm Ther. 2016;41:128-144.
  6. Choudhry AJ, Baghdadi YM, Wagie AE, et al. Readability of discharge summaries: with what level of information are we dismissing our patients? Am J Surg. 2016;211:631-636.
  7. Nguyen TN, Suh LC, Schilling AN. Impact of pharmacist intern-led discharge counseling in a community hospital. Poster presented at the 50th ASHP Midyear Clinical meeting; December 2015; New Orleans, LA.
  8. Kilcup M, Schultz D, Carlson J, Wilson B. Postdischarge pharmacist medication reconciliation: impact on readmission rates and financial savings. J Am Pharm Assoc (2003). 2013;53:78-84.
  9. McDonough RP. Community pharmacists: retailers or clinicians? May 2016. www.pharmacytoday.org/article/S1042-0991(16)30159-1/pdf. Accessed January 5, 2017.
  10. Guarini KL. Still struggling to find their role: community pharmacy participation in ACOs. August 21, 2015. www.pharmacytimes.com/publications/directions-in-pharmacy/2015/august2015/still-struggling-to-find-their-role-community-pharmacy-participation-in-acos. Accessed January 5, 2017.
  11. Thompson B. Collaboration during transition of care. February 2014. http://pharmacytoday.org/article/S1042-0991(15)31001-X/fulltext. Accessed January 5, 2017.
  12. Sen S, Bowen JF, Ganetsky VS, et al. Pharmacists implementing transitions of care in inpatient, ambulatory and community practice settings. Pharm Prac (Granada). 2014;12:439-446.
  13. Hume AL, Kirwin J, Bieber HL, et al; for the American College of Clinical Pharmacy. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012;32:e326-e337.
  14. Melody KT, McCartney E, Sen S, et al. Optimizing care transitions: the role of the community pharmacist. April 2016. www.dovepress.com/optimizing-care-transitions-the-role-of-the-community-pharmacist-peer-reviewed-fulltext-article-IPRP. Accessed January 5, 2017.
  15. Fera T, Ptachinski R. Reducing hospital readmissions: a new opportunity for community pharmacists. December 2013. http://insidepatientcare.com/issues/2013/december-2013-vol-1-no-2/18-reducing-hospital-readmissions-a-new-opportunity-for-community-pharmacists. Accessed December 13, 2016.
  16. Polinski JM, Moore JM, Kyrychenko P, et al. An insurer’s care transition program emphasizes medication reconciliation, reduces readmissions and costs. Health Aff (Millwood). 2016;35:1222-1229.
  17. Gibson N, Kebodeaux C, Smith K, et al. Identifying community pharmacists’ readiness to participate in transitions of care. Inov Pharm. 2015;6:Article 218.
Last modified: March 1, 2017
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