Ensuring that recently discharged patients recover safely and comfortably at home is one of the primary objectives of every hospital; yet, it can prove challenging. For an organization like Chicago-based Mercy Hospital & Medical Center, it was particularly so. Founded in 1852 to provide care for the city's underserved population, the hospital remains committed to delivering high-quality care to the city's residents, and specifically to Chicago's 300,000 uninsured.
Improving access to follow-up care is at the heart of Mercy's efforts to reduce unnecessary readmissions and repeat emergency department visits. Many patients Mercy admits are high-risk patients, so they are in jeopardy of being readmitted after discharge. Recognizing that medication management issues tend to be one of the primary reasons behind preventable readmissions, hospital leaders turned to the pharmacy team to find a collaborative solution. The team is led by Comprehensive Pharmacy Services, which manages Mercy's inpatient and outpatient pharmacy-related activities, 340B program, and pharmacy operations in several clinics and outpatient facilities.
Pharmacists bring unique clinical skills and expertise to care transitions that are key to helping patients achieve the greatest benefit from their medications. They have the clinical knowledge to discuss possible side effects, avoid drug interactions and eliminate duplicate medication therapies, all of which can cause patients to take less of their medication or discontinue it.
The pharmacy leadership team recommended piloting a multidisciplinary discharge clinic housed at Mercy's affiliate, the Mercy Family Health Center. The center is a community-based outpatient facility tightly aligned with the hospital and staffed by clinicians who deliver wellness care to adults, infants and children, and provide specialized services to seniors. It handles many of the more challenging cases, including patients with no primary care physician or insurance.
Because of its multidisciplinary approach to care, the Family Health Center was the logical location for the discharge clinic where a team consisting of a clinical pharmacist and nurse practitioner could reduce unnecessary readmissions.
With the support of hospital administrators, the discharge clinic opened in October 2013. The initial plan was to operate the clinic as a pilot program and evaluate its ability to prevent 30-day hospital readmissions and repeat ED visits.
The pharmacy team at Mercy Hospital worked collaboratively with the Family Health Center team to develop the right pharmacy protocol at the discharge clinic. The center's operations team scheduled the appropriate staff to support the pharmacist and nurse practitioner when the clinic opened.
In 2013, when the discharge clinic opened its doors for patient appointments six half days a week, with a pharmacist available for three out of the six half days. Patients were scheduled for 30-minute follow-up visits with a pharmacist and nurse practitioner. During the visit, the pharmacist conducted a comprehensive medication history and hospital course evaluation, and the nurse practitioner performed a physical assessment. On the days the pharmacist was not scheduled, the nurse practitioner conducted both assessments.
While reducing readmissions by any degree was considered a victory, the results posted within the first month of the discharge clinic's operations exceeded all of Mercy's expectations. Within the first month, readmissions of patients seen by the nurse practitioner decreased, and readmissions decreased even more significantly when the pharmacist and nurse practitioner saw the patient together.
DISCHARGE CLINIC READMISSION RATES
Mercy improved upon and sustained these results over the course of the first year of its discharge clinic's operation:
- In the first month, only 3 percent of at-risk patients se en by both the pharmacist and nurse practitioner were readmitted within 30 days of discharge vs. 15 percent of post-discharge patients who were seen by the nurse practitioner alone [see graph].
- By the end of the first quarter, the readmissions rate for at-risk patients seen by both the pharmacist and nurse practitioner dropped to 2 percent vs. 15 percent for at-risk patients seen only by the nurse practitioner.
- In the following three quarters, zero percent of the at-risk patients seen by both the pharmacist and nurse practitioner were readmitted, versus 11 percent, 17 percent and 8 percent, respectively, for the same time periods for at-risk patients seen only by the nurse practitioner.
- As a whole, the discharge clinic saw readmission rates for all its patients decrease from 7 percent in its first quarter to 1 percent a year later.
The program has been so successful that Mercy has increased dedicated staff, expanded pharmacist availability to all six half days, and extended access to the discharge clinic to all discharged Mercy Hospital patients.
The continued operation of the clinic has contributed to Mercy's ability to reach key quality measures by significantly reducing readmissions among an at-risk patient population. Through this initiative, patients have gained a better understanding of their medication regimens and health conditions, and now have access to the information they need to properly and confidently care for themselves and recover at home.
Daniel Vicencio, M.D., is the medical director of Mercy Family Health Center in Chicago. Steven Silverstein, PharmD, B.C.P.S., is the pharmacy health system director at Comprehensive Pharmacy Services in Memphis, Tenn. Andrius Cepenas, PharmD, B.C.A.C.P., is a clinical pharmacy specialist — ambulatory care pharmacy coordinator, with Comprehensive Pharmacy Services.