Laura McAuliffe, Pharm.D.; Andrew R. Zullo, Pharm.D., ScM, Ph.D.; Ruth Dapaah-Afriyie, B.Pharm., Pharm.D.; Christine Berard-Collins, M.B.A., R.Ph.
Lifespan Corporation – Rhode Island Hospital, Providence, RI
The risk of readmission within 30 days of hospital discharge is as high as 20%. Some pharmacist-managed transitions of care services targeting readmissions do exist; however, there is no guidance for how to identify patients likely to benefit from these continued services after they have had an initial appointment with a hospital-based transitions of care pharmacist. At our institution the pharmacy transitions of care service had lacked post-discharge follow-up. To address some of these gaps in care, it was identified that collaboration between the inpatient and outpatient settings would be beneficial. In order to leverage this potential opportunity for inpatient and outpatient collaboration, a practical prediction tool to identify hospitalized patients at highest risk for 30-day readmission at the time of discharge was developed and validated. This tool enabled inpatient pharmacists to discriminate patients likely to benefit most from continued outpatient pharmacy transitions of care services. As a result, various post-discharge follow-up programs were implemented.
In development of the prediction tool, the following variables were identified as significant independent predictors of 30-day potentially avoidable readmission after a transitions of care pharmacist encounter: no health insurance, public health insurance, use of ten or more medications at discharge, and having six or more chronic conditions at discharge. These variables formed the 3-predictor MEDCOINS score: medication count, comorbidity count, and health insurance status at discharge. Since development of this model, the MEDCOINS tool has been piloted as part of a post-discharge pharmacy transitions of care follow-up program. As of January 2017, patients are referred to the follow-up program by inpatient transitions of care pharmacists. If the patient is identified as having a high-risk of being readmitted within 30 days according to the MEDCOINS score, the inpatient transitions of care pharmacist refers the patient to the MEDCOINS follow-up program. The follow-up service was initially pharmacy resident-driven. During follow-up encounters the pharmacist takes part in an interaction with the patient to conduct a thorough medication review. When preliminarily reviewing data from the pilot phone follow-up program, approximately 19.6% of patients reached upon pharmacy phone follow-up were readmitted within 30 days compared to 23.5% of patients who were not able to be reached. In addition to using the MEDCOINS tool to implement a pharmacy discharge phone follow-up program, an interdisciplinary complex care clinic has been piloted in which patients are seen in the outpatient setting after hospital discharge. During the visit, patients are seen by a pharmacist, social worker and provider. A portion of patients referred to the clinic are those who were seen by an inpatient transitions of care pharmacist and identified as high-risk according to the MEDCOINS tool. There is a potential for increased reimbursement for these services with the use of CMS Transitional Care Management (TCM) codes.
This tool has proven to be simple yet effective for pharmacists to use, identifies reasons why patients may be readmitted despite being seen by a pharmacist, and has facilitated the implementation of various post-discharge programs that have improved our ability to reduce hospital readmissions.