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The rate of hospital readmissions has been declining following the the launch of the Hospital Readmissions Reduction Program (HRRP) in 2012
Robert Oscar, R.Ph.The rate of hospital readmissions declined slightly in the fourth quarter of 2012 following the launch of the HOSPITAL READMISSIONS REDUCTION PROGRAM (HRRP), while reimbursements for hospitals with excess readmissions decreased by 1% in 2013.
Hospital reimbursements are expected to decrease by an additional 2% in 2014 and 3% in 2015, according to the U.S. Centers for Medicare and Medicaid Services (CMS), the agency that initiated the program.
The HRRP penalizes hospitals when patients with heart attacks, heart failure or pneumonia are readmitted within 30 days of discharge. By 2015, acute exacerbation of chronic obstructive pulmonary disease and elective total hip and knee anthroplasty will join the conditions that could trigger penalties. CMS chose the conditions based on their impact on patient volume and costs.
CMS estimates that the cost of readmissions for Medicare patients is $26 billion annually. More than $17 billion of that amount can be saved if patients receive appropriate care during their first admission, according to CMS. The HRRP went into effect on October 1, 2012. CMS reported that the 30-day, all-cause readmission rate dropped to 17.8% in the fourth quarter of 2012 after averaging 19% for the previous five years, translating into an estimated 150,000 fewer hospital readmissions among Medicare beneficiaries.
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The Dartmouth Institute says that the biggest factors behind readmissions are:
Thomas Graf, MDThomas Graf, M.D., chairman of the GEISINGER HEALTH SYSTEM practice service line, credits the HRRP with motivating hospitals to adopt quality measures. His company created the Proven Health Navigator (PHN) Medical Home Initiative in 2006 in part to help reduce hospital readmissions. PHN helps facilitate patient follow-ups with primary care physicians within five to seven days of discharge.
To address readmissions, nurse case managers call patients within 48 hours and review medications, making sure they understand the need for them.
Geisinger has seen an approximate 36% reduction in readmissions annually since 2007 in sites backed by PHN, according to Graf.
About one-fourth to one-third of readmissions are due to medication problems such as non-adherence, estimates Robert Oscar, R.Ph., president and chief executive officer of Richmond, Virginia-based RxEOB, a provider of software applications for health plans and pharmacy benefits.
Oscar points to medication reconciliation-reviewing what a patient was prescribed prior to admission and post-discharge-patient education, and electronic information exchange among providers as important factors during the transition of care process.
Reconciliation helps avoid medication omissions and duplications that stem from patients being prescribed brand and generic drugs, says Oscar.
“Educating patients soon after discharge ensures they understand what they were taking before and after hospitalization in case there have been changes,” says Oscar.
It also helps them understand what to expect from a new drug so as to prevent non-adherence, how to access new drugs, and how to manage insurance issues, he adds.
“When patients do not know what they are taking and why, it could put them back into the hospital,” says Oscar, who notes that pharmacists are in the best position to manage drug reconciliation.
With so many older adults on polypharmacy, Oscar emphasizes the need to work directly with patients. Caregivers at patients’ homes and doctors at long-term care facilities need to know all medications that a patient is taking.
Health systems need to engage staff to oversee patients after discharge. “Management should not stop once patients walk out the door,” Oscar says.
Marybeth Terry, PharmDMarybeth Terry, Pharm.D., president, Southern Pharmacy Services in Pink Hill and Kernersville, North Carolina and Wytheville, Virginia, knows all too well the challenges associated with older adults and their multi-medication regimens. The pharmacy addresses the medication problems for residents of assisted living and skilled nursing facilities, adult care homes and independent living communities.
Terry believes that in many cases hospitals discharge patients without sufficient information.
“If patients’ drugs are not reconciled after discharge, they can forget to take them and will land back in the hospital,” she says. “We have to look at patients as a whole, not just provide a Band-Aid approach.”
She applauds the HRRP for putting pressure on hospitals to focus more on patients at discharge.
Noting that health plans have access to patient information and are focused on quality ratings, she says they have an opportunity to keep track of members during transition periods.
Terry agrees with Oscar that a lack of adherence, lack of understanding, and lack of coordination regarding medication can lead to hospital readmissions. She belives pharmacists are in the best position to monitor a patient’s drug use.
But a study published in the Journal of Managed Care & Specialty Pharmacy showed that providing comprehensive medication management services post-discharge did not have any significant effect on readmissions or emergency department visits at 30 days, 60 days and six months after discharge.
Other studies have indicated that interventions by pharmacists have helped reduce readmission rates.
Southern Pharmacy relies on consultant pharmacists to work with doctors at different facilities to keep abreast of prescriptions because non-adherence is a major issue for many of the patients the pharmacy serves, Terry says.
Southern Pharmacy initiated a program in 2003 that monitors patients who are transitioning from a hospital to a long-term care facility. Pharmacists analyze patients’ disease states; compare medications prior to admission and at discharge; identify red flags such as duplications, omissions, adverse side effects and interactions; stay in communication with doctors; and keep track of all medications.
Terry says consultant pharmacists are available 24/7 to handle problems and to follow up with physicians if patients are not taking their medications appropriately. She says that it is not just a question of non-adherence but also improper doses and administration, along with misunderstanding by patients of why they are taking a particular drug.
Mari Edlin is a freelance writer based in Sonoma, Calif.