BETHESDA, MD 12 February 2013—Now that patients with heart failure at The University of Kansas Hospital interact with pharmacists at admission, transfer, and discharge, the 30-day readmission rate for this patient population has dropped, said assistant director Samaneh T. Wilkinson.
"One could certainly speculate that . . . our new practice model had something to do with that," she said. "But it’s hard to say that we did it alone and we impacted 100% of those" patients without examining each one’s electronic health record.
This new practice model, which focuses on transitions of care, got underway at the Kansas City hospital this past October 1, Wilkinson said.
October 1 was also the start of the first fiscal year during which the Centers for Medicare and Medicaid Services links quality to payment in the inpatient prospective payment system: reductions in payments to acute care hospitals with excess 30-day readmissions of Medicare beneficiaries and incentive payments to hospitals with above-par performance on certain measures.
Pharmacy personnel, said director Rick J. Couldry, now manage medication reconciliation and drug-related issues in transitions of care for all inpatients.
His hospital has 576 staffed beds.
He said the most important reason for the practice model is "because this is really the right thing for pharmacists to be doing for their patients."
In the three months leading up to rollout of this practice model, Wilkinson said, 22.6% of the patients who were discharged after hospitalization with heart failure returned as inpatients within 30 days.
The rate was 14.7% for the practice model’s first month, she reported, noting that this figure is the most recent one available.
Significant additions. To implement the practice model, Couldry said the department added a "significant number" of full-time equivalent (FTE) positions, not all pharmacists, in 2012.
He declined to publicize the exact number.
"This is the culmination of a nine-year effort," Couldry emphasized. "Samaneh conducted probably 8 to 12 pilots over a nine-year period to be able to collect data" to support the request for more personnel.
That data, he said, included the number of minutes to complete a medication reconciliation, the number of mistakes a pharmacist finds during medication reconciliation versus the number found by a nurse or physician, the types of interventions made by pharmacists, and the effect these interventions have on patient satisfaction.
"The pay-for-quality measures with the government payers is something that helped kind of push it over the top and . . . drive us to what indicators we would measure," Couldry said.
Wilkinson said the acute care units have 1 pharmacist for every 30 patients. This pharmacist-to-patient ratio was chosen because it was roughly the ratio at some of the health care organizations that successfully provided medication reconciliation for all inpatients. On the critical care units, the ratio is 1:20.
If not for geography, Couldry said the ratio on the critical care units would be the 1:18 that Wilkinson wants.
"You might have three patients in a service on one unit and three more patients on the same service on a different unit two floors away," he explained. "It makes it difficult to staff as efficiently as we’d like."
In addition to pharmacists’ services to inpatients with heart failure, Couldry said, the department in September added an FTE pharmacist to the hospital’s primary heart failure outpatient clinic.
The pharmacist is actually two people who job-share the responsibility. He said this arrangement ensures that the clinic, which serves 500–600 patients, has a dedicated pharmacist seeing patients 40 hours a week.
Meaningful measures. As for inpatients in general, Wilkinson said, 95% of those who have walked into the hospital since October 1 have spoken face to face with a pharmacy representative during the admission process.
Inpatients with heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease receive special attention at discharge, she said.
"We’re trying to make sure that a pharmacist does discharge counseling on those patient populations," Wilkinson said, "because we know that those patient populations are at a higher risk for readmitting to an organization than some of the others."
The entire process of discharge counseling takes about 35 minutes, she said. Patients tend not to have a lot of questions for the pharmacist. The most time-consuming activities have turned out to be reconciling the medication orders in the electronic health record and squaring away the documentation.
Despite not asking pharmacists lots of questions about discharge medications, patients do remember they had the opportunity, Wilkinson said.
Responses to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey are proof.
"Those numbers are improving as well," she said.
By partnering with the organizational improvement department, Wilkinson said, the pharmacy department can report recent 30-day readmission rates and relevant HCAHPS survey responses to the hospital’s leadership team.
"One of the things that our leadership team wanted from us was metrics to show the impact of the addition of . . . that high number of FTEs," she said.
Translating the department’s importance to outcomes of patient care, Couldry said, was "the cornerstone of how this project got approved."
"All of pharmacy . . . needs to start thinking about demonstrating our value as pharmacists as it relates to measures like 30-day readmission rates because those are the measures that hospital leaders care about and understand," he exhorted. "We can’t be that profession that measures our value in interventions because no one [else] understands what that means."