Avoidable Readmissions

In the past year, more than 2200 hospitals have been penalized $280 million for “excessive” readmission rates under the Centers for Medicare & Medicaid Services’ (CMS) Readmissions Reduction Program, and the penalties will become more severe as the maximum penalty rises to 3% by 2014.

As most health care leaders are aware, CMS is focused on readmissions because nearly 20% of hospitalized beneficiaries are readmitted within 30 days of discharge, representing almost 2 million hospitalizations per year. The cost is more than $9700 per readmission, at a total cost to Medicare of $17.5 billion. According to many estimates, up to 75% of these readmissions may be preventable.

So why are there so many preventable readmissions? Not surprisingly, medication misadventures can play a major role. These issues include unfilled prescriptions, poor patient knowledge, lack of medication reconciliation, and adverse events.

Ambulatory Pharmacy’s Role in Reducing Readmissions

Extensive evidence shows that ambulatory pharmacy can play a key role in helping to reduce readmissions in 4 specific ways:

• Reconciling medications. Before discharge, a pharmacist verifies a patient’s medication history, clarifies that prescribed medications and doses are appropriate, and reconciles discrepancies. Medication reconciliation can prevent up to 70% of potential errors and 15% of adverse drug events.
• Ensuring that prescriptions are filled. An ambulatory pharmacy can help ensure that prescriptions are filled before patients leave the hospital.
• Educating patients about their drugs. Hospitals are having pharmacists spend time with patients before discharge, at which point they proactively teach patients about their medications and may include medication therapy management (MTM).
• Following up post discharge. Pharmacists perform phone-based follow-up to ensure that patients are taking their medications and to reduce adverse events. Through efforts targeting high-risk patients, Massachusetts General Hospital found medication-related problems in more than 50% of the calls completed by the pharmacy. The post discharge intervention helped decrease readmission rates by 50% among this population.

Through these varied interventions, hospital-based ambulatory pharmacies are making a significant difference in reducing readmissions.

Reducing Readmissions: Case Studies

• RARE (Reducing Avoidable Readmissions Effectively). In Minnesota, 82 hospitals and 6 health systems set goals to reduce 30-day readmissions, improve Hospital Consumer Assessment of Healthcare Providers and Systems scores, and decrease health care costs. Pharmacists use the teach-back method to engage patients prior to discharge regarding their medications, conduct medication reconciliation at transitions of care, and schedule follow-up appointments. Since 2011, 3603 readmissions have been prevented.
• Novant Health (North Carolina). A pharmacist-led team at Novant Health uses pharmacists to provide post discharge medication follow-up. Through this program, 30-day readmissions for adverse drug events were decreased by 1.4% and overall readmissions by 6.1%.
• Hennepin County Medical Center (Minnesota). During a pilot program started in 2010, discharged patients who had received high levels of inpatient service were identified. Within 3 to 5 days post discharge, they were engaged in MTM visits. The pilot program reduced admissions by 42%, emergency department visits by 37%, and the cost of care by approximately $2500 per member per year.

Hospitals and health systems are now considering their options when it comes to starting or expanding their ambulatory pharmacy operation—to own and operate their own ambulatory pharmacy or to outsource to a third-party retailer. There are certainly pros and cons to both scenarios.

By outsourcing to a third-party retailer, the hospital is delivered a fully operational pharmacy on their property with minimal work required from the hospital. There are many financial models for an outsourced pharmacy, including an attractive lease rate back to the hospital, a percentage of the pharmacy’s total revenue, or a combination of both. However, potential benefits of hospital-run programs extend far beyond financials. They also include control and design of programs to reduce readmissions, prescribing errors, drug-related discrepancies, drug administration errors, and morbidity and mortality for certain conditions. Additionally, studies document how hospital-owned and -operated programs have improved patient satisfaction and health outcomes.

Conclusion

Hospital-based ambulatory pharmacies have taken hold and are gaining momentum. A recent survey found that 34% of hospitals already operate an ambulatory pharmacy and 48% of larger urban hospitals do so. More than half of hospitals with an ambulatory pharmacy (58%) plan to expand their ambulatory pharmacy offerings.

Ambulatory pharmacies can help improve outcomes and patient satisfaction, increase revenue, and decrease readmissions. They extend the hospital’s reach into the community and extend the continuum of care.

Robert Scholz, RPh, MS, MBA, is the vice president, pharmacy practice consulting for McKesson Pharmacy Optimization. He leads a team of pharmacy professionals providing health care/ hospital consulting service in areas such as revenue enhancement, supply chain improvement, packaging, barcode readiness, Lean Six Sigma process improvement, 340B optimization, and ambulatory pharmacy.