Reducing hospital readmissions continues to be a challenge for providers. Direct costs of readmissions, excluding ED and observation admissions, easily exceed $26 billion a year. The readmissions situation becomes even more critical to provider financial viability given that more than 80 percent of 3,080 hospitals evaluated by the Centers for Medicare and Medicaid Services (CMS) face penalties in FY 2021 as part of its Hospital Readmissions Reduction Program (HRRP).
It is no surprise, then, that providers are increasingly open to exploring new ways to ensure that once patients are discharged, they do not boomerang right back for conditions that could have been anticipated, and possibly prevented, with better discharge planning and aftercare management.
Recognizing this challenge, SAC published a blog several years ago on how better post-discharge follow-up creates a win-win situation for providers and patients alike. And while more integrated approaches to discharge planning, management and aftercare appear to have impacted readmission rates, the current number of hospitals still being penalized under HRRP suggests there is still more that providers can and should be doing to further reduce these rates. Doing so could provide a much-needed boost to providers’ bottom lines, as well as reduce the physical and emotional toll these readmissions take on affected patients.
On-staff hospital pharmacists can be a cost-effective and readily available piece of the solution for many providers. Given that more than 10 percent of 30-day hospital readmissions can be attributed to adverse drug events (ADEs), the bulk of which are preventable, these care team members could almost be considered a provider’s secret – or perhaps better said, underutilized – weapon in reducing readmissions.
Almost half of all patients have a clinically significant medication error within a month after discharge. These types of errors along with general prescription noncompliance and ADEs create a perfect storm for readmission risk. Patients face several challenges in complying with their medication instructions included in their discharge plans, many of which hospital pharmacists – along with their community pharmacist partners – can readily address.
These include the following:
• Low health literacy: Many patients have a basic understanding, if they have any understanding at all, about healthcare in general, and about medications in particular. In fact, more than 85 percent of Americans are not as “health literate” as they should be, and this can greatly impact patient medication compliance after discharge. To give a tangible example of how important health literacy is, one hospital reported about a diabetic patient who was prescribed daily insulin shots. As is common practice, the hospital staff taught him how to inject the insulin by practicing on an orange. Shortly after leaving the hospital, he was back with high blood sugar levels. It turns out that when he got home, he continued to inject the insulin into an orange and then ate the orange pieces. How did this happen? The man simply did not understand what he was supposed to do. He was not health literate. There is also evidence that at discharge, only 64% of patients can say the indications of their medications and only 11% of patients knew their medications’ expected side effects. This situation is exacerbated by incorrect and/or incomplete lists of medications patients should take at home.
• Poor access to medications after discharge: Even if patients understand what medications they should be taking after discharge – and how and when to take them – 8 percent of medication access challenges take place within the first two to three days after discharge. If a patient finds it difficult to get the medications indicated at discharge, this could increase the probability they simply will not take them. This, of course, can increase the risk of readmission with 30 days of discharge.
• Confusion about medications post-discharge: Even if patients understand their discharge instructions on how to take their medications, some may have conditions or find themselves in life situations that make compliance difficult or increase the risk for ADEs. These include being older, having cognitive impairment, prescribing cascades, and polypharmacy.
• Financial challenges: Patients may find themselves in a maze of Medicare, Medicaid, private insurance, and self-pay discount programs for covering the costs of their medications post discharge. The resulting confusion – and often frustration – can delay securing needed medications or, in some cases, put medications out-of-reach for patients unable or unwilling to navigate the healthcare system.
Maximizing the Value of the Hospital Pharmacists
In addition to their primary responsibility of ensuring safe and effective use of medications as part of a patient’s treatment plan, staff pharmacists have expertise and experience that could prove valuable in resolving post-discharge prescription compliance challenges.
These include patient education, laboratory test analysis, medication management systems, community outreach and even patient advocacy.
Various studies suggest that perhaps the most effective way to maximize hospital pharmacists’ value in reducing readmissions is to better integrate them into both inpatient treatment and discharge planning teams. In this way, they can best help in mitigating or resolving the challenges patients face that result in post-discharge ADEs and prescription noncompliance.
Examples of ways hospital pharmacists can help with readmissions
• Patient education: Hospital pharmacists should accompany the medical team on patient rounds. In addition to answering patient questions at bedside, this approach to patient education can also help the hospital pharmacist develop a better rapport with the patient. This may give the patient the confidence to ask questions at discharge as well as afterward. Part of this education process can include detailed medication reconciliation; “teach back” exercises to ensure the patient fully and correctly understands their post-discharge medication plan; illustrated medication schedules; and small, wallet-sized medication lists. Providers with patient portals should also include instructions on how to use it post-discharge to review medications and how to take them, order refills, and ask questions directly to the hospital pharmacist. One study from Hong Kong showed that this type of pharmacist intervention lowered the risk of unplanned healthcare utilization within 30-days of discharge by some 60 percent.
• Ongoing follow-up and patient inquiry response: Given that discharge is just the first step in patient aftercare, it is important to proactively follow-up with patients on their medication regimens to help ensure compliance. Assuming the hospital pharmacy staff was part of patient rounds and met with patients during the discharge meeting, patients should be more likely to accept the team’s follow-up calls. Research suggests that these types of calls can decrease the number of ADEs as well as readmissions and even ED visits. In one study from Britain, for example, this type of follow-up reduced 30- and 90-day hospital readmissions by 9.9 percent and 15.2 percent, respectively.
• Liaising with community pharmacists: Much the way a TOC plan would include a medical “hand off” to a patient’s personal physician and other healthcare providers, the hospital pharmacist team can play the same role with the patient’s local pharmacy to ensure their medication records are updated and accurate. The local pharmacy, for its part, could give the hospital pharmacist information on whether a patient has received and/or refilled their prescriptions on time. This would, of course, help the hospital pharmacist team with their patient follow-up calls. They could also help coordinate payor and/or discount programs with community pharmacies to minimize patient financial challenges.
While more research needs to be done on the benefits of integrating hospital pharmacists into interdisciplinary discharge planning teams, there are several successes worth mentioning.
One pilot study at an academic medical center, for example, showed that a multifaceted, pharmacy-driven TOC program resulted in a six percent reduction in 30-day readmissions among the patients receiving this type of discharge counseling. Another showed a 9.2 percent reduction in 30-day readmission rates among the patients receiving medication reconciliation and counseling. And in yet another study, patients who received counseling by a pharmacist at discharge showed a medication adherence rate of approximately 84 percent while the control group showed an adherence rate of around 62 percent. These sessions also reduced readmission rates with the control group having a 24 percent readmission rate and the group receiving counseling having a readmission rate of 3 percent.
In addition to expanding the hospital pharmacist role in discharge planning and patient education, among others, providers may also want to consider investing in hospital pharmacist team training and education. This ongoing will not only help ensure the team maintains its professional competency, but also could support ongoing efforts at improving staff morale and retention.