Pharmacists Help Small Kansas Hospital Cut Readmissions

BETHESDA, MD — Because of its designation as a critical access hospital, 25-bed Community Memorial Healthcare in Marysville, Kansas, isn't required to manage its rate of 30-day readmissions to secure full reimbursement for the treatment of Medicare beneficiaries.

But the hospital is nonetheless working to reduce readmissions and has made pharmacists an integral part of the process.

"We do it because it's good for patients," said Sherrie Harrison, the hospital's quality director.

By working now to identify and resolve problems that affect 30-day readmissions, Harrison said, the staff will know what to do if critical access hospitals someday lose their exempt status under Medicare's Hospital Readmissions Reduction Program.

Harrison said the hospital's rate of 30-day readmissions dropped by about 16% during the most recent quarter.

Paula Winkler, director of pharmacy, said the timing coincided with the hospital's June hiring of Staff Pharmacist Emily Dunsing to help Winkler manage admission and discharge medication reconciliation.

How it works. The pharmacists' readmission-prevention efforts involve essentially every patient at the small hospital and not just people with certain conditions or medication profiles.

Dunsing said the process starts with developing and reconciling an accurate medication list for incoming patients.

"We're either meeting with patients or going out and looking at any papers they come with and trying to get all of their medications [accurately listed] before they're even admitted to the floor," she said.

During the hospital stay, she said, the pharmacists identify patients who may be at high risk for readmission within 30 days—for example, because they don't understand how to properly use their inhaler or insulin pen.

"We're also trying to identify any patients who are leaving on any new medications and . . . visit with them before they're discharged," Dunsing said.

She said one of the most common problems encountered during the admissions process is the lack of accurate dosage information.

At discharge, Winkler said, a common challenge is to ensure that patients receive prescriptions for the optimal dosage forms and strengths of their medications.

That's because during the inpatient stay, the pharmacy's limited inventory may necessitate tablet splitting or the ordering of multiple tablets to achieve the correct dosage.

"When patients are discharged, [our] challenge would be to order the proper form of that medication . . . so that the patient doesn't have to break a tablet or take two of a tablet where they could just take one" at home, Winkler said.

The medication reconciliation process also helps to identify patients who aren't taking their medications as prescribed because they can't afford them.

"We are lucky that we do have a financial assistance specialist pharmacy technician as well as our [regular] pharmacy techs," Winkler said.

HEN's role. Community Memorial Healthcare's focus on readmissions actually began about three years ago through participation in the state's Health Engagement Network (HEN).

HENs were launched in 2011 as part of a Centers for Medicare and Medicaid Services (CMS) initiative to support safer care.

Harrison said the HEN led to "several different quality initiatives, and one of them was readmissions. So we've been tracking all-cause readmissions for quite some time now."

"The HEN team looked at what possible factors were influencing our readmissions—and medication was an integral part of that," Harrison explained. "And we have a great pharmacy staff that did take the lead in that."

CMS in 2015 cited HENs as part of a larger federal effort that prevented 50,000 patient deaths, avoided 1.3 million adverse events, and saved $12 billion in overall healthcare costs over a three-year period.

According to the American Hospital Association and the Health Research & Educational Trust, which led most HENs at the national level, the initiative prevented more than 65,000 hospital readmissions from 2011 through 2014 and avoided more than $572 million in associated healthcare costs. Preliminary data from 2015 and 2016 suggest that over 8,000 additional readmissions were prevented in those years.

CMS ended its support for HENs in September 2016, replacing the program with a new Hospital Improvement Innovation Networks initiative and awarding $347 million to entities participating in that effort.

Continuation. Harrison said the readmissions focus is likely to continue indefinitely at Community Memorial Healthcare.

"I don't see us letting up," she said. "We've seen a nice trend in the last three years, and especially in the last year, of a decrease in readmissions."

Winkler emphasized that it's a group effort. On weekends, medication reconciliation falls to the nursing staff.

"We are full-time pharmacy staff, so we only work five days a week. We do not work on weekends on the floor," Winkler said. "But we are on call 24-7."

With training from pharmacists, she said, the nursing staff is able to educate patients about their medications. That includes discussing with patients what medications they are receiving and why they were ordered and also explaining the need for any new medications.

During postdischarge phone calls, nurses ask patients whether they have any questions about their medications. If so, the nurse puts the patient in touch with the hospital's pharmacy staff or recommends follow-up from the prescriber or community pharmacy, as appropriate.

Winkler said she and Dunsing participate in hospital rounds when possible and have also trained other healthcare providers to use the medication reconciliation components of the electronic medical record system.

"So when they see any issues or concerns, they call us immediately so that we can [act] prior to that patient being dismissed or discharged," Winkler said.

She said potential issues include discharge prescriptions that weren't properly processed at a community pharmacy and mismatched or inaccurate discharge instructions.