By Todd Sloane
Medicare is set to dock the pay of nearly 2,600 hospitals by $528 million in fiscal year 2017 due to excessive readmissions—an all-time high and an increase of about 25 percent from fiscal year 2016. Four years into the Centers for Medicare & Medicaid Services’ Hospital Readmissions Reduction Program, many hospitals report they have been unable to make a dent in their recidivism rates, in part because the program penalizes hospitals for any readmission, regardless of whether it is a direct result of one of the six conditions covered by the program. That is problematic when the covered conditions, such as chronic lung disease and congestive heart failure, are difficult to treat and often are accompanied by significant comorbidities, making these patients the “frequent fliers” who overrun emergency rooms.
An underlying issue in many readmissions, however, may contain the seed of a new way to reduce them. Studies show that two-thirds of emergency readmissions for patients over 65 are the result of preventable medication errors that include sound-alike drugs wrongly included in prescriptions, patients failing to notify doctors about other drugs they have been taking, serious medication side effects and patients failing to fill needed prescriptions or unintentionally taking incorrect medications or dosages. On average, two or more medication mistakes occur for every hospital discharge.
Efforts to reduce readmissions have focused particular attention on the discharge transition from hospital to home—a point at which patients are vulnerable and often are dealing with complex and changing care regimens. “Too much is happening in that last hour in the hospital, too many pieces of paper and voices coming at the patient, who just wants to get home,” says Jeff Lackman, RPh, division vice president of RxRemote Solutions, a subsidiary of Comprehensive Pharmacy Services (CPS), a national provider of hospital pharmacy management and consulting. “You can talk to patients all day about medications, and they won’t remember a thing once they hit the parking lot.”
Lackman’s team provides remote medication reconciliation services to hospitals, including follow-up phone consultations with patients to ensure they received the right prescriptions, filled them, are taking the medications correctly and do not have contraindicated drugs at home. A 2012 study published in the Journal of General Internal Medicine found that 81 percent of discharged patients either experienced a provider medication error or had no understanding of at least one intended medication change. “When the patient has had a chance to settle back in their home, we find they can retain information much better,” he says.
The RxRemote team actually first engages at admission with a review of the patient-provided medication list. “We as pharmacists have realized over the years that when mom says she takes two blue pills at bedtime for her diabetes, that’s a problem for us,” Lackman says.
That list is then compared to the patient’s medication history in the electronic record, but that often does not include information from primary care doctors and retail pharmacies. A national retail database is used to validate home medication lists and assess patient compliance. At discharge, the list is refined again to include take-home medications and address any discrepancies.
“We find patients who have duplicate meds, having a new script for a brand name and a generic they had at home, which they resume taking,” says Marvin Finnefrock, Pharm.D., divisional president, Clinical & Purchasing Services at CPS. “It is no small thing to be on two blood thinners or blood pressure drugs at the same time. That right there will land you back in the hospital pretty quickly.”
An article published in the July issue of the health services research journal Health Affairs reported on an insurer-initiated care transition program based on medication reconciliation delivered by pharmacists via home visits and telephone calls with high-risk patients. It found a 50 percent reduction in 30-day readmissions, aided by the close ties of the insurer and a pharmacy benefit manager with full, or nearly full, information on medications prescribed.
Only in the past several years have a significant number of hospitals been making post-discharge phone calls, and most of the calls are made by nurses or primary care doctors’ assistants, not by clinical pharmacists with experience in medication reconciliation. CPS is one of the few vendors to provide the service remotely.
Similarly, discharge medication reconciliation is not always done well, Lackman says. Although it has been a Joint Commission National Patient Safety Goal since 2005, much of what hospitals do is to simply comply with what amounts to a checkoff list. “You get recommended medication and doses, but it doesn’t always take into account a patient’s individual health history, so a patient with poor kidney function may not be able take a certain drug or dose,” he says. “There’s checking off the boxes, and then there’s meeting best practices, following up to find adverse drug reactions and root causes. One meets the standards, the other starts to solve the problems, so we keep people out of the hospital.”