Strategies to Overcome the Readmission Crisis in Health Systems

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

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

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:

• Be proactive. Being proactive from the day of admission is one of the most important aspects of any readmissions reduction program. Start with obtaining a comprehensive medication history and performing admission medication reconciliation. Then, work collaboratively to prepare the patient and his or her medication plan in preparation of discharge. Being proactive sets up an efficient discharge process and effective transition from the acute care to the ambulatory care setting.
• Prepare a “warm hand-off” note. The warm hand-off note summarizes the pertinent medication changes that occurred during the patient’s admission and communicates to the next provider the most important medication follow-up needs. This note should be placed in the medical record in a location that can be accessed by the next pharmacist to care for the patient.
• Involve both day and evening staff. At our institution, both daytime and evening pharmacist staff take part in the TOC program. Staff that work daytime shifts often know the patient and plan of care to a greater degree and take a lead in performing discharge medication reconciliation and writing “warm hand-off” notes for the next provider. Evening staff are instrumental in performing admission medication reconciliation and performing the final patient education as directed by day shift staff.
• Work collaboratively with nursing. The patient’s nurse is often the individual most acutely aware of the patient’s needs and plans for discharge. By working collaboratively with nursing, the pharmacist can be kept in the loop about time of discharge and does not need to scramble at the last minute to ensure their portion of the transition process is completed.
• Utilize risk stratification to identify patients at greatest risk. Our institution targets patients at moderate and high risk for readmission based on criteria that include number of chronic disease states, number of hospitalizations in the past year, and number of medications. This allows us to utilize limited pharmacy resources to target the patients most likely to be readmitted.
• Ensure close follow-up. Patients should have plans for close follow-up of changes made during the hospitalization. This can be as robust as a posthospital discharge follow-up clinic or as simple as a follow-up phone call and should be based on the patient’s acuity and level of complexity. Either way, programs for ensuring safe transitions and reducing readmission should not end with hospital discharge.

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.

Resources

• Centers for Medicare & Medicaid Services. Readmissions reduction program. www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Updated August 4, 2014. Accessed October 1, 2015.
• American Society of Health-System Pharmacists; American Pharmacists Association. ASHP-APhA medication management in care transitions best practices. American Pharmacists Association website. http://media.pharmacist.com/practice/ASHP_APhA_MedicationManagementinCareTransitionsBestPracticesReport2_2013.pdf. Published February 2013. Accessed August 29, 2014.
• Giberson S, Yoder S, Lee MP. Improving Patient and Health System Outcomes through Advanced Pharmacy Practice: A Report to the US Surgeon General 2011. Rockville, MD: Office of the Chief Pharmacist, US Public Health Service; December 2011. www.accp.com/docs/positions/misc/improving_patient_and_health_system_outcomes.pdf.
• Jack BW, Chetty VK, Anthony D, et al. A reenginered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-187.
• Warden BA, Freels JP, Furuno JP, Mackay J. Pharmacy-managed program for providing education and discharge instructions for patients with heart failure. Am J Health-Syst Pharm. 2014;71(2):134-139. doi: 10.2146/ajhp130103.
• Kirkham HS, Clark BL, Paynter J, Lewis GH, Duncan I. The effect of a collaborative pharmacist-hospital care transition program on the likelihood of 30-day readmission. Am J Health-Syst Pharm. 2014;71(9):739-745. doi: 10.2146/ajhp130457.
• Pal A, Babbott S, Wilkinson ST. Can the targeted use of a discharge pharmacist significantly decrease 30-day readmissions? Hosp Pharm. 2013;48(5):380-388. doi: 10.1310/hpj4805-380.
• Society of Hospital Medicine. Overview: project BOOST implementation toolkit. www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/Overview.aspx. Accessed October 2, 2015.
• Cavanaugh JJ, Jones CD, Embree G, et al. Implementation science workshop: primary care-based multidisciplinary readmission prevention program. J Gen Intern Med. 29(5):798-804. doi: 10.1007/s11606-014-2819-8.