An Atlanta hospital saw an immediate improvement in patient satisfaction scores—and a dramatic decrease in readmissions—after implementing a proactive approach to ensure patients get and take their medications after discharge.
DeKalb Medical has reduced the odds of readmissions by approximately 40 percent among patients who receive a specialized pharmacist intervention, according to preliminary findings presented at the Forum12 conference in September 2012. Pharmacists at the outpatient retail pharmacy fill and deliver prescribed medications to patients’ bedsides at discharge and offer education and follow up after patients leave the hospital. Patients in the care transition program had a lower 30-day readmissions rate than patients in the same hospital in the year prior to program initiation (5.6 percent compared to 10.6 percent).
The program is a partnership between Atlanta-based DeKalb and the operator of the outpatient retail pharmacy. All patients who are discharged to their homes are eligible for this service. The program was implemented at DeKalb’s North Decatur facility in January 2011 and the Hillandale campus in January 2012.
“One of the main reasons patients come back to the hospital is that they don’t follow their medication instructions correctly,” says Solomon Tafari, MD, MPH, medical director of DeKalb Medical’s Hospitalists. Since October 2012, more than 2,000 hospitals have been financially penalized for high readmission rates by the Centers for Medicare & Medicaid Services (CMS). Penalties range from 0.01 percent to 1 percent of a hospital’s total Medicare revenue.
Patients who don’t take their prescribed medications or use them incorrectly cost the U.S. healthcare system $290 billion annually, according to Waste and Inefficiency in the U.S. Health Care System Clinical Care: A Comprehensive Analysis in Support of System-Wide Improvements by the New England Health Care Institute. In addition, the Institute of Medicine report, To Err is Human, found that medication errors are estimated to cause more than 7,000 deaths annually. Many of these errors may be avoided by increased pharmacist-led patient education.
Tracking Medications at Admission
When hospital patients are asked for a list of their current medications on admission, they may forget to list a drug, or they may not know what drugs have been prescribed to them. To ensure that DeKalb physicians and nurses can make the best clinical decisions for patients based on their current medical histories, pharmacists help the hospital staff compile a medication list for patients. If there are some medications that a patient should no longer take, the pharmacist can discontinue such medications in the database to prevent medication duplication, unsafe interactions, or other future errors.
Ensuring Patients Take Medications
Taking medications correctly means beginning the prescription promptly. Within 1-3 hours of a DeKalb patient’s scheduled discharge, a pharmacy technician or pharmacist physically delivers medications to the patient or caregiver. Delivery of medications to the patient’s bedside ensures that DeKalb patients leave the hospital with their medications, reducing the significant number of unfilled discharge prescriptions. Up to one quarter of prescriptions written in hospitals are unfilled, according to a study “Prevalence, Predictors, and Outcomes of Primary Nonadherence After Acute Myocardial Infarction,” published in Circulation. Patients who delay taking prescribed medications or miss a dose experience slower recoveries and may require hospital readmission.
Payments for bedside delivery prescriptions are handled in the same manner as they are in a retail pharmacy. The pharmacy staff processes the insurance verifications and approvals and collects copayments from the patient.
“Another important advantage that DeKalb has identified with bedside delivery is that we frequently find out that a prescribed discharge medication is not covered or that the patient cannot afford the copayments. The pharmacist and case managers then have an opportunity to intervene before patients leave the hospital unable to fill their prescriptions, which often leads to subsequent readmissions,” says Jacquelyn Paynter, executive director for Care Management at DeKalb.
The pharmacists also offer patients education and training to ensure they take their medications properly. Educational topics include medication indication—the clinical reasons for using the medication—the importance of medication therapy to a patient’s overall health, side effects, and methods to negate side effects (e.g., taking some medications with food). The pharmacists also address insurance and financial issues the patient may have, such as substituting a covered drug for one that is not covered by the patient’s plan.
Staying Involved Beyond Discharge
Another important component of DeKalb’s program is follow up after hospital discharge. Two CMS programs—readmission penalties and the bundled payment initiative—are extending a hospital’s responsibility for patient care beyond the discharge date. Post-discharge follow up by primary care providers, nurses, or pharmacists is an important component of a hospital’s strategy to reduce its risk of readmission penalties and high-cost readmissions.
Two days after discharge, pharmacists call DeKalb patients’ homes or cell phones, depending on the patient’s preference, to discuss the initial days of medication therapy. Pharmacists assess compliance with the medication plan, ensure that patients still understand drug regimens, and address new questions or concerns. “We have found that the best times to call are in the early afternoon. The calls may not elicit any questions, but they open the door for patients to feel comfortable with calling back in the future if a question or concern does arise,” says Austin Mudd, a pharmacist who works for the pharmacy operator at DeKalb Medical.
Integrating Pharmacists into the Clinical Staff
DeKalb includes pharmacists in regular meetings with the healthcare team. Pharmacists contribute in the following ways:
- Working with physicians to resolve drug interactions or dosing concerns
- Consulting with social workers to address patients’ affordability concerns
- Collaborating with case managers to ensure medications that require prior authorizations are approved by a patients’ insurance coverage
- Assisting nurses with drug therapy counseling, especially for injectable medications
- Helping with discharge plans
Contributing to Patient Satisfaction
Originally, the partnership between DeKalb and the pharmacy operator was introduced to raise the hospital’s HCAHPS scores. For two consecutive years, DeKalb received its lowest patient satisfaction rating on its ability to communicate medication requirements. However, within the first 90 days of the pharmacy partnership, patient satisfaction with the medication component of HCAHPS rose from 50 percent to 63 percent. Pharmacists at DeKalb are continuing to work with the service excellence manager to support improvements in HCAHP scores.
Recognizing the Key Role of Medication Adherence
Hospitals and health systems are facing new challenges to improve quality of care, reduce readmissions, and respond to emerging initiatives such as bundled payments. DeKalb’s positive results from its medication adherence program demonstrate that the pharmacist will be a key player on the healthcare team in coming years.
Ian Duncan is an adjunct associate professor in the Department of Statistics and Applied Probability at UC Santa Barbara, and vice president, outcomes and analytics, Walgreen Companies, Deerfield, Ill. (firstname.lastname@example.org).
Publication Date: Thursday, February 28, 2013