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Pharmacy Departments Innovate to Reduce Readmissions Penalty

Cheryl A. Thompson

With two thirds of acute care hospitals hit financially by the Hospital Readmissions Reduction Program, pharmacy departments are trying to ensure that inpatients do not need another hospital stay for at least 30 days.

Four hospitals whose pharmacy directors agreed to describe some of their department’s efforts each face the prospect of losing $1 million or more in Medicare payments this year, according to public reports.

The financial penalty under the federally legislated program can amount to as much as 1% of the payment per Medicare-covered hospital stay this current fiscal year.

That penalty applies to hospitals that the government determined had excess 30-day readmissions from July 2008 through June 2011 for Medicare beneficiaries with any of the following conditions: myocardial infarction, heart failure, and pneumonia.

On October 1, the start of fiscal year 2014 for the government, the maximum penalty goes up to 2%.

All acute care hospitals paid under the inpatient prospective payment system, the Centers for Medicare and Medicaid Services decided, are targets of the program.

Bedside prescription transactions. At 1167-bed Barnes-Jewish Hospital in Saint Louis, the mantra has become "every patient goes home with their medications," said pharmacy director James L. Gray III.

Patients who leave the hospital with their discharge medications in hand, courtesy of the new Mobile Pharmacy program, tend to have a lower readmission rate than the rest, Gray said. But this downward trend, he added, is "not statistically valid yet."

Part of the impetus for the program came from the hospital’s discovery that some patients had problems obtaining discharge medications once home, said Valerie Garber, the program’s supervisor. Sometimes the hometown pharmacy had closed for the day by the time the patient arrived. And sometimes a medication was not something normally in stock, which could mean a delay of several days, she said.

As for the hospital’s outpatient pharmacy, Gray said, few discharged patients could find it on the roughly 16-square-block campus.

So he asked the hospital’s emerging technologies group to develop a bedside equivalent to the outpatient pharmacy’s service window.

Garber said the result, technologywise, is a smartphone with an attachment from Grabba International Pty Ltd. Pharmacy technicians from the Mobile Pharmacy program use the combination device to scan bar codes, swipe credit cards, and collect signatures when delivering discharge prescriptions to patients in their rooms.

Since November 2012, Garber said, the program has been bringing all the services of the outpatient pharmacy, including the opportunity to speak with a pharmacist, to patients every day from 9 a.m. to 9 p.m. on 21 of the care units.

On average, for the eight weeks ending January 5, 36.3% of the patients on those units who went home from the hospital had prescriptions filled by the program, Garber reported.

Broken down by care unit, she said, the capture rates run about 34% for medicine, 25% for cardiology, and 67% for orthopedics.

The remaining 22 units will get the program by mid-2013, she said.

"Patients almost universally want it," Gray said.

He projected that the capture rates will rise once more nurses and case workers routinely mention the Mobile Pharmacy program to soon-to-be-discharged patients.

Education for all with heart failure. Now that Cleveland Clinic pharmacists counsel all patients with heart failure about their medications, the internally tracked readmission rate of that group has decreased by 2.2 percentage points, said Scott Knoer, chief pharmacy officer.

The pharmacists also support the health system’s program in which patients receive a phone call 48 hours after discharge. Last year, Knoer said, patients had some sort of question about medications during about 1200 of the phone calls, and pharmacists responded.

Pharmacy’s efforts are part of multidisciplinary initiatives to decrease readmission rates at a health system whose main hospital, he said, has a 1300-patient census and the highest case-mix index in the nation.

Knoer said the pharmacy in November 2011 declared that pharmacists "will counsel all heart failure patients across the enterprises." This mandate applies to the main campus in Cleveland, the eight hospitals in northeast Ohio, and the hospital in Florida.

At the regional hospitals, he said, the pharmacists also counsel all patients with acute myocardial infarction or pneumonia.

"We’re in the process of rolling it out on the main campus," Knoer said. "But it’s so much bigger [than the other hospitals], and there are so many more patients. This is a little bit more complex."

Validation of medication reconciliations. At Tufts Medical Center in Boston, a pharmacy technician who previously worked at a community pharmacy validates the medication reconciliations performed by physician residents for patients admitted to the general medicine service, said pharmacy director Ross Thompson.

Although this pilot program entered only its fourth month in January, Thompson said Tufts expects its rate of unintended readmissions of patients with pneumonia to decrease. These patients typically are under the care of the general medicine service.

So far the pharmacy technician, whom Thompson called "a really good communicator," has spoken with about 400 patients.

He said an early analysis revealed that she found at least one discrepancy—very often one of clinical consequence—in about 46% of the medication reconciliations.

"The technician is spending maybe 20 [or] 25 minutes on average with the patients, including contacting retail pharmacies, getting everything done such that the pharmacist comes in and spends about 8 minutes," Thompson said.

Hiring someone who already knew how to get information from community pharmacies and ensure patients could access their medications in the community proved beneficial, he said. That was the piece that the staff would have had difficulty teaching. Patient flow and the workings of the general medicine service were not difficult subjects for the staff to teach.

Thompson said the grant funding the pilot program comes from a performance-based payment from Blue Cross Blue Shield of Massachusetts to the Tufts-affiliated physicians network.

Beyond reconciliations. Pharmacy director Edward G. Szandzik at Henry Ford Hospital in Detroit said his pharmacists are in the second year of an "extended pilot" targeting patients with heart failure or chronic pulmonary obstructive disease, both of which increase the risk of pneumonia.

"We’re not only addressing discrepancies" in the medication history on admission, Szandzik said, "we’re looking at assessing adherence and ability for the patients to pay for those meds postdischarge."

The pharmacists document what they find and solve in the progress notes of the electronic health record that employees, including those in the health system’s 1200-physician group practice, can access, he said. Likewise, the pharmacists can access that electronic health record to determine what transpired before patients’ admission to the hospital.

"Communication is the big thing, especially in these transitions of care," Szandzik said.

In that spirit, he said, the hospital’s pharmacists will start indicating in the electronic health record the need for a pharmacist on the ambulatory care medication management team to check on a patient three to five days after discharge.

Clinic for at-risk patients. Szandzik said a pharmacist from nearby Wayne State University just started working at the hospital’s internal medicine clinic for patients at high risk for readmission.

This clinic, he said, attempts to see at-risk patients three to five days after hospital discharge, before the routine follow-up appointment with their physician.

Details on which of these patients will see the pharmacist have not been finalized, Szandzik said.