BETHESDA, MD 09 Mar 2016—Home visits from clinical pharmacists can reduce hospital readmission rates for homebound patients, according to results of a pilot study conducted by Bloomington, Minnesota–based HealthPartners.
The integrated healthcare organization announced in February that 6% of 31 patients who received comprehensive medication therapy management (MTM) services at home were readmitted within 30 days of hospital discharge, compared with 16% of 121 patients who weren't visited by a pharmacist.
"We started to go out to their homes in July of 2014. And what we've seen so far has been very promising," said Daniel Rehrauer, senior manager of the MTM program.
Rehrauer said the home visit project, which is part of his organization's wider efforts to reduce 30-day hospital readmission rates, targets elderly homebound patients who are dually eligible for Medicare and Medicaid.
According to the Centers for Medicare and Medicaid Services (CMS), the rate of all-cause 30-day hospital readmissions among fee-for-service Medicare beneficiaries was 17.5% during 2013. CMS has estimated that U.S. hospitals overall will face about $420 million in penalties for excessive 30-day readmission rates for Medicare beneficiaries during fiscal year 2016.
At HealthPartners, two pharmacists who work directly for the organization provide MTM services in patients' homes at no cost to the patients. The pharmacists work with case managers, home care services, and other care providers to solve problems found during visits.
"The home visits are very interesting because we do uncover some other issues—not only medication issues but social issues as well," said clinical pharmacist Annie Danielson.
Danielson said much of her MTM work involves patient education and medication reconciliation to make sure a patient is on the correct therapy.
"We do a lot of simplifying too," said clinical pharmacist Madelyn Atol. She said regimen simplification makes it easier for patients to adhere to their medication plan.
Atol said part of her work involves ensuring that patients have a consistent place and method to "set up their medications" so that each drug is taken as prescribed. She helps ensure that patients have a well-designed pillbox for organizing medications and uses individualized strategies, such as smartphone alarms, to help patients remember to take each dose at the right time.
The home visits allow the pharmacists to take care of issues that aren't readily addressed through a phone call.
"During a home visit, we can pull in family members. So we can find out who is taking care of the patient [and] who is setting up their medications. Do they have a support system? And sometimes over the phone you don't get that interaction with the caregivers," Danielson said.
She also said patients can show her exactly where they store all of their medications, including expired drugs that have been stashed away for a decade or longer and require disposal.
Rehrauer said his organization also pays for pharmacists to visit patients at home outside of the pilot program, generally by referral.
The Medicare program has also been exploring whether coordinating home visits from primary care clinicians is an efficient way to provide primary care services to homebound patients. The Independence at Home demonstration program, which began enrolling healthcare practices in 2012, provided more than $10 million in incentive payments to participants during the program's first year.
Pharmacists are among the clinicians who can be part of primary care teams for the demonstration program, according to CMS. At least one Independence at Home practice group includes a clinical pharmacist [see July 1, 2015, AJHP News].
Rehrauer said medication-related issues that HealthPartners pharmacists find during the home visits differ from the problems encountered in other patients receiving MTM services.
"In our overall program, by far and away the number-one problem that we find is that people need additional therapy to treat their conditions, and a close second is that their doses are too low," Rehrauer said. "And in our home care patients, we see exactly the opposite. The biggest problem that we identify is no longer having the need for certain medications."
Rehrauer acknowledged that using pharmacists for home visits is costly for the healthcare organization.
"If I can have a pharmacist seeing three or four patients a day and driving 50 or 60 miles a day, that's a lot more expensive than having [pharmacists] be in a clinic and seeing 13 patients a day," he said. "But I think we've seen, in this type of patient population, that we're able to have a beneficial effect."
Rehrauer said the organization's overall MTM program was first launched in 2006 and has delivered an 11:1 return on investment for HealthPartners' costliest patients.
But he estimated that only about 5,000 of the roughly 850,000 patients who are entitled to the organization's MTM benefit actually used it last year.
"That's an area that we're trying to improve upon," Rehrauer said.
Rehrauer said a major obstacle to expanding MTM services is that patients don't understand that the program is available to them. He said surveys have shown that the main reason patients decline to participate in the comprehensive MTM program is that they believe their physician or pharmacist already performs these services.
"It shows a lack of understanding of what it is that we're doing," he said. "We're going to be having a big push to increase the use of MTM services across our health plan. Sustainability is not the issue—it's how do we get more of it."