Collaboration in transitional care

In 2011, poor transitions in care cost the U.S. healthcare system $45 billion. Of the 1.5 million medication errors that harm patients each year, approximately 60% occur during transitions in care.

A study report published three years ago in Health Affairs noted that 20% of Medicare beneficiaries who had been hospitalized were readmitted within 30 days and 34% were readmitted within 90 days. In addition, about 13% of Medicare beneficiaries experienced at least three provider handoffs within the 30-day post-discharge period, said Mary D. Naylor, the study’s lead author, who reviewed the literature to identify transitional interventions that positively affect hospital readmission rates.

ACA support

The Affordable Care Act of 2010 provided funding for the Community-Based Care Transitions Program - $500 million over five years, starting in 2011 - for health systems and community groups that offered at least one transitional intervention for high-risk Medicare patients.

The ACA also established the Center for Medicare and Medicaid Innovation to support innovative care delivery and payment models that include transitions of care. From 2011-2019, the Center is expected to provide $10 billion for these demonstration pilot programs, said Naylor, who is Marian S. Ware Professor in Gerontology in the School of Nursing at the University of Pennsylvania, Philadelphia.

To bend the curve in the hospital readmission crisis, the ACA also instituted a program to reduce readmissions by penalizing health systems that show excessive readmissions for patients with heart failure, heart attack, and pneumonia. In October 2012, the Readmission Reduction Program reduced payments to hospitals by 1%, which will climb to a 3% penalty by next year.

Medication management

In 2012, in an issue brief, the NEHI, a national health policy institute, highlighted the need for greater medication adherence and the role of medication management to improve patient outcomes.

“Medication management is at the core of advanced discharge planning and transitional care. This reflects three realities: adverse events are a major cause of avoidable hospital readmissions; most post-discharge adverse events are related to drugs rather than other causes, and lack of adherence to medications prescribed at discharge has been shown to be a driver of post-discharge adverse drug events,” the NEHI issue brief stated.

The NEHI brief called for hospitals to implement best practices related to medications and adherence by:

• Improved efficiency in taking medication histories and better use of electronic prescribing;

• Increased use of non-physician clinicians, including community-based nurses and pharmacists for post-discharge follow-up on medication use;

• Improved techniques for patient engagement and counseling for patient self-management;

• Use of technologies for medication monitoring and patient reminders.

STAAR initiative at MGH

Adoption of advanced discharge planning and transitional care has also been encouraged by the Institute for Healthcare Improvement (IHI) and its State Action on Avoidable Rehospitalizations (STAAR) initiative.

Laura CarrMassachusetts General Hospital (MGH) in Boston was one of three initial teams to participate in the STAAR initiative, said Laura Carr, PharmD, the senior attending transitional care pharmacist at MGH, speaking at this year’s American Pharmacists Association annual meeting about the interventions the hospital implemented from July 2010 through July 2013.

Each STAAR hospital team focused on four targeted interventions:

• Performance of an enhanced assessment of post-hospital needs [basically a discharge plan];

• Provision of effective teaching and facilitating enhanced learning;

• Provision of real-time hand-over communications;

• Delivery of timely post-hospital-care follow-up.

New interventions

In addition to the four primary efforts targeted under STAAR, MGH also established two new interventions focused on the role of the discharge nurse in providing discharge care and the role of the pharmacist in providing transitional care.

On the hospital floor, the discharge nurse took the lead in facilitating communications with all healthcare providers. She encouraged providers to reflect on the impact their care would have on both the patient’s length of stay from the time of admission and the subsequent discharge. She also identified high-risk patients for inclusion under the inpatient STAAR initiative and was the source of all referrals to the transitional care pharmacist, Carr noted.

High-risk patients were taking 10 or more medications and had one of the following conditions: heart failure, pneumonia, acute renal failure, atrial fibrillation, cancer pain, dehydration, urinary tract infection, or change in mental status.

During the 3-year STAAR initiative, the transitional care pharmacist was involved with pre- and post-discharge interventions. Pre-discharge interventions for high-risk patients discharged to their homes included medication reconciliation, medication review, medication access, and face-to-face counseling. For high-risk patients discharged to another facility, the pre-discharge responsibilities included medication reconciliation and medication review.

MGH findings

“During the STAAR initiative, 35% of the high-risk patients had medication-related issues of clinical significance,” Carr said. “These were medication lists that had already been reviewed by their physicians and their nurse. So pharmacists have a big role here.”

In addition to these inpatients chosen for interventions, a pharmacist identified another group of high-risk patients for post-discharge intervention. On average, these patients were taking about 12 medications and were associated with 2.3 medication discrepancies.

During the post-discharge follow-up, pharmacists found that 52% of patient calls were associated with medication-related issues. This increase in post-discharge interventions occurred because patients were responsible for their own care and frequently had difficulty following instructions, said Carr.

“The most common medication-related issue that we found was difficulty following proper dosing instructions, which frequently occurred with anticoagulants,” she said. “Unfortunately, we had a lot of patients going home who were on Lovenox [enoxaparin sodium] with a bridge to Coumadin and didn’t realize proper dosing instructions.”

Medication access

“We also had patients not starting new medications and doses,” Carr said. “We were surprised by the number of patients who were called three days post-discharge. They had been in the hospital a week with pneumonia and still hadn’t been to the pharmacy to pick up their antibiotics.”

There were also medication access issues that were seen in this high-risk patient population. This was a frequent issue with Lovenox.

“Patients would go to the pharmacy and their co-pay was $1,400. Or patients needed prior authorization for medications and were just going without or waiting for their one-week follow-up to get prior authorization or to talk with their physician about prior authorization.”

During the three-year STAAR initiative, MGH’s interventions were able to reduce readmission rates for high-risk patients. For pre-discharge interventions, patients who received the pharmacist intervention had a 16% hospital readmission rate vs. the 27% rate for those who didn’t receive interventions.

Patients who received post-discharge interventions had 13% hospital readmission rate vs. a 17% rate for patients who were discharged but didn’t receive interventions.

NACDS Foundation grants

In May, the National Association of Chain Drug Stores (NACDS) Foundation announced that it had awarded three grants totaling $1.8 million to study the impact of community pharmacist collaboration in medication management and avoidance of hospital readmissions.

Geisinger Health System, based in Pennsylvania, and its 37 different pharmacy partners will analyze the impact of pharmacist collaboration for high-risk inpatients and outpatients and continued follow-up for 180 days. The Health Collaborative - involving University of Cincinnati Hospitals, Mercy Jewish Hospital, and others in Cincinnati, Ohio - is partnering with 45 Kroger pharmacies to study the integration of electronic health information into pharmacist-provided medication therapy management (MTM) for high-risk patients, with continued follow-up for 180 days.

The University of Mississippi School of Pharmacy and the University of Mississippi Medication Center will also study the impact of pharmacist-provided medication management on hospital readmissions. Approximately 20 Walgreens pharmacies will be involved in bedside medication delivery before hospital discharge, telephone follow-up post-discharge, and face-to-face MTM and development of an adherence action plan.

Kathleen Jaeger“We looked for research grants that had physician engagement, care coordination, team approach, scaleability, recordability, and innovative interventions,” said NACDS Foundation President Kathleen Jaeger, PharmD.

Access to data was very important because the multidisciplinary team needs to coordinate care and leverage its technology for discharge summaries.

“Everyone on the care continuum, from the hospital to the primary care physician to community pharmacy - all need to have the right information,” Jaeger said.

“With these grants, our focus is to see whether we can improve patient care and help patients avoid being readmitted to a hospital, and whether we can help them be adherent to their medications so that they can improve their outcomes,” she said.

Geisinger Health System

Eric WrightPatients who are discharged from an acute-care healthcare setting are typically given their prescriptions just before discharge, and they are responsible for filling their prescriptions and taking them appropriately. However, as Eric Wright, PharmD, lead researcher for the Geisinger grant project, explained, the pre-discharge instructions and counseling are not always heard by the patient.

“The patient may not know how to coordinate the medications, as the instructions may have changed and the patient is confused,” Wright said. “We would hope that the community pharmacist filling those prescriptions would be able to assist. The problem is [the community pharmacist] doesn’t get a lot of the pieces of information that are needed to know what is going on with a patient from the hospitalization.

“Our goal here is to link the inpatient pharmacist to the outpatient pharmacist - giving a brief on what happened during hospitalization from a medication standpoint. We give them the patient’s medical history and medication list, and let them know if there are any medication-related issues that they need to follow up with,” he continued.

Using a secure e-mail system known as Direct, inpatient pharmacists at Geisinger will be able to transmit HIPAA-compliant healthcare information to other providers with Direct accounts. Geisinger is still working on some elements of this system before the project launches in September, Wright said.

The community pharmacist advantage

At Geisinger Health System, inpatient pharmacists get to know the patients because as part of the interdisciplinary team, pharmacists accompany physicians as they make their rounds.

The advantage of working with the community pharmacist is that the community pharmacist usually has a relationship with the patient established before the hospitalization. The community pharmacist can leverage that existing relationship to influence the patient’s behavior at the critical point - right after discharge, Wright said.

During this project, Geisinger Health System will partner with a variety of pharmacies, including Caresite Pharmacy, its own network pharmacies; Weis pharmacies (a regional chain); Medicine Shoppe and Medicap Pharmacy (franchise independents); and Harrold’s Pharmacy (an independent).

“When I approached [Medicine Shoppe and Medicap], they were so excited about this opportunity, they jumped right on a call with me and had their VP and others on board,” Wright recalled. “It was great to get Medicine Shoppe and Medicap involved.”

The program

For 180 days, the community pharmacies working with Geisinger will follow high-risk patients who were hospitalized for heart failure, acute myocardial infarction, pneumonia, and chronic obstructive pulmonary disease.

Patients will receive pre-discharge medication reconciliation and counseling from the Geisinger inpatient pharmacist.

Within 24 to 48 hours post-discharge, community pharmacists will reach out to patients or the patients’ caregivers to make initial contact. In three to seven days, the pharmacists will call to see whether patients are having any adverse reactions to their medications and whether there are any signs of early nonadherence. When a patient comes into the pharmacy to obtain medications, the pharmacist will carry out a 15-minute face-to-face intervention.

“I think that early phone call is going to be helpful. Then the pharmacist will touch base with them on a monthly basis for the next six months to make sure that they are doing okay,” Wright said.

Impact of community pharmacies

Julie Olenak

Gary KarwaskiJulie L. Olenak, PharmD, a clinical pharmacist and director of clinical programs at the Medicine Shoppe in Dallas, Penn., and Gary Karwaski, RPh, owner of the Dallas Medicine Shoppe store, are pleased with the opportunity to participate in the Geisinger project.

“We are looking forward to documenting the impact of community pharmacists,” said Olenak, who is also associate professor at Wilkes University School of Pharmacy, Wilkes-Barre, Penn.

“At this pharmacy we run several clinical programs already. So this was a natural fit for us, to volunteer to participate in this project.”

With three pharmacists participating - Olenak, Karwaski, and Karwaski’s daughter, Beth Karwaski, PharmD - the pharmacy is in an excellent position to provide MTM. In addition, their pharmacy has been recognized as a specialized immunization center and diabetes center. The pharmacy also offers a formal smoking cessation program, an important patient service for individuals with cardiovascular disease, and a hypertension clinic.

“We also provide cholesterol, blood glucose, and metabolic syndrome assessments,” Olenak noted. “Gary has been very committed in developing services beyond dispensing, in partnership with the school and myself.”

On the healthcare team

Bette McDonaldBette McDonald, RPh, a senior franchise business consultant for Cardinal Health, who was instrumental in the involvement of six Medicine Shoppes and one Medicap store for the Geisinger project, is happy that these pharmacies are part of a cutting-edge study.

“This is one of the first types of studies to show the value of the retail pharmacist in the community as part of the healthcare team,” McDonald said. “For years pharmacists have had the tools and ability [to contribute], and yet we’ve not really been recognized for what our capabilities are, in terms of involvement in the healthcare team. My pharmacists are really excited about being able to utilize the skills that they’ve had for years and be recognized for them.

“From a healthcare perspective, the role that we would like to play as part of the healthcare team is to prove that we can actually help in readmissions and help cut the cost of healthcare,” McDonald said.