Targeting better patient outcomes through care transitions, adherence
Here’s a fact that keeps health plan administrators and anyone else responsible for budgeting health costs awake at night: 1-in-5 hospital patients ends up back in the hospital within 30 days of their discharge. And the biggest factors pulling them back all have to do with medications — either through medication errors, nonadherence or adverse drug events.
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That’s according to the Centers for Medicare and Medicaid Services, which put the cost of those revolving-door readmissions at $25 billion or more a year. Other estimates peg the cost as high as $44 billion, according to physician Stephen Jencks, a health consultant and senior fellow at the Institute for Healthcare Improvement.
Many of those costly trips back to the hospital could be avoided, said Jencks and other health experts, if there were better systems in place for transitioning patients from the hospital to the home or long-term care center — and improved coordination of care between the hospital and a local safety net of health providers, including pharmacies, clinics and physician groups.
In recent years, a number of pharmacy companies, big and small, have stepped up to prove that theory correct, developing innovative partnerships with local hospitals and health systems, all built around one fairly simple idea: getting the community pharmacist more actively involved in a patient’s transition from the hospital to the home, and helping them understand the critical importance of taking their medications as their doctors have prescribed. The results to date have been impressive, driving down 30-day hospital readmission rates about 50% for patients who have been part of these programs.
Plenty of factors are fueling the push for more coordination between hospitals, community pharmacies and other health entities. Among them is the critical need among public and private health plan payers to curb the staggering costs of hospital care.
“High-cost hospital care … is a major driver of national health expenditures,” said Karen Utterback, VP of strategy and business development for McKesson’s Extended Care Solutions Group. “If you want to tame national health expenditures … you must lower inpatient hospitalization rates.”
Also driving the transitions-in-care movement are the health reform dictates spawned by the Affordable Care Act of 2010, including the focus on quality of care and the shift in payments by Medicare and Medicaid from fee-for-service to outcomes-based reimbursements.
“With value-based hospital payment penalties now in place for excessive 30-day readmission rates, and a call for improved care coordination by the Affordable Care Act, improved models of care are necessary,” noted the American Journal of Managed Care.
“The ACA added force to new payment models that reward outcomes and penalize poor performance, such as high rates of readmission and hospital-acquired conditions,” agreed PricewaterhouseCoopers in a 2015 report on new health trends. “The ACA fueled this trend. For providers, the law took steps to change how Medicare pays for care by offering financial incentives and penalties that encourage better care coordination, higher-quality outcomes and less fragmentation.”
Indeed, the White House is pushing for federal health reimbursement changes “that would put as much as half of what it spends on Medicare into alternative payment models by 2018,” PwC’s Health Research Institute reported.
That shift away from fee-for-service to outcomes-based payments to hospitals is accelerating their urgent drive to discharge patients back into the community care setting more quickly and spread the risk burden among a team of community-based provider partners.
Pharmacists ‘at core of transitional care’
The stampede toward a more seamless transition of care between the hospital and the home is right in line with what Paul Abramowitz, CEO of the American Society of Health-System Pharmacists, called the “continued movement toward quality and coordinated delivery of care.”
“Studies have demonstrated that successful coordination and management of transition of care services lower costs by positively impacting hospital read mission rates,” Abramowitz said. “When pharmacists are involved, access is increased, quality is improved and costs are reduced.”
Anne Burns, VP of professional affairs for the American Pharmacists Association, agreed with that assessment. “We’re moving to a value-based healthcare system where providers, hospitals and other organizations are going to be paid based on their ability to both generate positive outcomes and control costs,” Burns said. “New care delivery models, such as patient-centered medical homes, are expanding across the country. Pharmacists are increasingly being incorporated into these models as members of inter-professional healthcare teams that collaborate and better coordinate the care of their patients.”
Even at this late stage, however — more than two years after full implementation of the Affordable Care Act, and well into the quality-and outcomes-based health payment reforms mandated by the ACA for Medicare — not enough attention is being given to the potential contributions that community pharmacy can make to reducing the readmission rate for patients transitioning from hospital to home.
“Ineffective care transition processes lead to adverse events and higher hospital readmission rates and costs,” according to a report from the Joint Commission’s Center for Transforming Healthcare. “One study estimated that 80% of serious medical errors involve miscommunication during the hand-off between medical providers.”
However, the commission noted, “readmissions within 30 days of discharge can often be prevented by providing a safe and effective transition of care from the hospital to home or another setting.” And among the collaborative-care activities that can have “very positive effects on transitions,” its report added, is “medication reconciliation, with the involvement of pharmacists.”
NEHI, a national health policy institute, agreed. In a study, the group found that a large percentage of hospital readmissions are caused by medication-related adverse events. “Medication management is at the core of advanced discharge planning and transitional care,” the health policy group reported. “This reflects three realities: adverse events are a major cause of avoidable hospital readmissions; more post-discharge adverse events are related to drugs than other causes; and lack of adherence to medications prescribed at discharge has been shown to be a driver of post-discharge adverse drug [events].”
NEHI urged the creation of integrated, multi-disciplinary healthcare teams — including community pharmacists — to improve post-discharge patients’ health and lower hospitalization costs.
Improved medication adherence reduces hospital readmissions
Much of the flow of patients back into the hospital can be traced to medication nonadherence. “The lack of adherence — not taking medications, not taking the right medications or taking the right medications the wrong way — is estimated to be the cause of nearly one-third of readmissions of patients with chronic medical illnesses,” Utterback noted.
The nonadherence problem goes far beyond the post-discharge patient population, however. When patients fail to take their medicines as prescribed, or don’t even have their prescriptions filled in the first place, it shortens lives for thousands of Americans and generates enormous extra health costs each year.
Poor medication adherence results in $290 billion of avoidable costs in the healthcare system, according to NEHI. And the breakdown in a patient’s planned medication therapy often occurs right after the doctor writes a prescription; according to NACDS, “25% of patients fail to pick up their initial prescriptions, leading to poor outcomes and preventable complications.”
It’s a problem that goes right to the heart of community pharmacy’s core competencies. Boosting adherence levels — both among post-discharge patients and among the total population — is an increasingly critical focus for pharmacy providers.
Chain and independent pharmacies around the country are stepping up efforts to partner with local hospital groups and health systems in a massive campaign to create a long-term, post-discharge safety net for patients after their release from the hospital. National pharmacy providers, such as Walgreens, CVS Caremark, Rite Aid, Walmart and others, all have long-term initiatives in place to align with hospital systems and help patients transition back into the community, as do such regional players as Thrifty White and Hy-Vee.
Walgreens’ WellTransitions program, launched in 2012 in partnership with local hospital systems in several markets, has shown solid results, yielding a 46% reduction in unplanned hospital readmissions within 30 days of discharge for patients who were part of an outcomes study, according to the company.
And Rite Aid has grown its Health Alliance transition-of-care partnership, which involves collaboration between some of its stores and several health systems around the United States. The program is reducing readmissions and improving patient outcomes through the formation of closer working relationships between post-discharge patients, physicians and Rite Aid pharmacists, said a company official, and through a careful tracking of all pharmacist-patient interactions and results.
With support from their wholesaler partners, many independents also are forming post-discharge patient-care networks. “As our country moves to a value-based model that rewards better outcomes, it’s critical for community pharmacists to demonstrate and measure how they can drive medication adherence and improved health,” said Doug Hoey, CEO of the National Community Pharmacists Association.
To help drive the transitions-of-care movement, several pharmacy companies have partnered with leading healthcare organizations and universities to conduct major research efforts on the success of such programs, including:
- A collaboration between Walgreens and the University of Mississippi’s School of Pharmacy and Medical Center to examine the impact of pharmacist-provided medication management on hospital readmissions. The project involves 20 local Walgreens pharmacies and the Mississippi division of Medicaid.
- A study of how pharmacists’ interventions and continuous care can reduce hospital readmissions among high-risk patients in Pennsylvania. Participants include Geisinger Health System, Weis Markets, Medicine Shoppe and Medicap pharmacies and Wilkes University College of Pharmacy and Nursing.
- An analysis of the impact of integrating electronic health information with pharmacist-provided medication management following a patient’s discharge from the hospital in several counties in Ohio. Partners include 45 Kroger pharmacies, the University of Cincinnati’s James L. Winkle College of Pharmacy, UC Health West Chester Hospital, Mercy Health Hospitals and the Greater Cincinnati Health Council.
- A study of emerging healthcare models — and their impact on patient outcomes — involves Thrifty White Pharmacy, Walgreens, the University of Iowa, University of Nebraska Medical Center, North Dakota State University, Blue Cross Blue Shield and OutcomesMTM.
Managing U.S. population health — pharmacy steps into frontline role
For decades, the pharmacy profession labored under a widespread, but inaccurate, public perception of pharmacists as little more than dispensers of prescription medicines and givers of basic counseling on their use. No more. Pharmacists today are highly trained, clinically engaged patient-care specialists making a huge and rapidly growing impact on population health management in communities all over America.
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“The vast majority of pharmacists today are already doing much more than simply filling prescriptions,” noted Dr. Harry Leider, chief medical officer for Walgreens. “They’re helping patients manage chronic disease, providing medication management services, conducting health tests to diagnose conditions like diabetes or high cholesterol, and administering a wide range of immunizations. They’re also partnering with healthcare providers working in nearby health systems and hospitals, serving as part of care teams to help improve patient health and outcomes.”
It goes without saying that medication dispensing and counseling remain a critically important part of successful health outcomes. That’s even more the case in an era of increasingly specialized, highly targeted biotech drugs requiring careful administration, dosage management and monitoring of their effects.
“Medications play such an important role in the treatment of acute and chronic illnesses, but treatment regimens can be complex and patients often don’t understand how and why to use their medications appropriately,” noted Anne Burns, VP of professional affairs for the American Pharmacists Association.
“Increasingly, pharmacies provide vaccinations, health education and disease state testing and management,” the National Association of Chain Drug Stores reported. “Through personal in- teractions with patients, face-to-face consultations and convenient access to preventive care services, pharmacies are helping to shape the healthcare delivery system of tomorrow — in partnership with doctors, nurses and others.”
As the practice of pharmacy has expanded and evolved, so too has the public’s perception of the pharmacist as a highly skilled, clinically trained frontline health provider. A large majority of Americans embrace the idea of getting vaccinations, point-of-care testing and other preventive health services from their local pharmacist, according to public polling.
In a nationwide survey of consumers sponsored by NACDS in 2015, 79% of respondents voiced support for pharmacists as a resource for “administering vaccinations and immunizations for preventing or treating illnesses, such as the flu, hepatitis, pneumonia and tetanus.” More than 7-in-10 also expressed support for using pharmacy-based retail clinics for primary healthcare services, and nearly two-thirds of those polled said pharmacies should be allowed to administer blood, urine or strep tests.
U.S. consumers also are voting with their feet. Hundreds of thousands of Walmart customers flocked to the company’s first-ever chainwide wellness and screening event — held last October and dubbed “America’s Biggest Health Fair” — for free health tests, low-cost flu shots and counseling. “We did nearly 300,000 screenings, with [more than] 50,000 customers processed per hour,” said Alex Hurd, senior director of product development, growth and payer innovations at Walmart health and wellness. “We had nurses doing the screenings, and our pharmacists did about 52,000 immunizations.”
Among those screened were some 7,000 customers who had little or no insurance coverage. And some 3,000 of those screened were shown to be diabetic or at risk of having diabetes, according to the Walmart executive.
Pharmacy chains also are providing cost-effective and accessible healthcare solutions through a growing network of in-store walk-in clinics staffed by nurse practitioners and physician assistants. More than 2,000 pharmacy-based retail clinics are now open nationwide, according to the Convenient Care Association. They’re offering acute-care services for minor injuries, upper respiratory ailments and other conditions, along with an expanding menu of services to treat chronic disease, with no appointment necessary, at a fraction of the cost of a visit to a doctor’s office or emergency room.
Americans’ new vaccination resource
One of the primary ways community pharmacies now contribute to public health is through vaccinations against a wide variety of diseases. Tens of millions of Americans now get their annual flu shots at their local pharmacy, saving time and money and relieving the stress on the nation’s overburdened family physicians and clinics.
Costco Wholesale’s pharmacies alone provided some 700,000 vaccinations last year for influenza, shingles and other conditions, according to Michael Mastromonica, assistant VP of pharmacy for the wholesale club giant, and this year its pharmacists have begun providing travel vaccinations, as well. He sees immunization and vaccination services as the point of the spear for the whole spectrum of retail health services now offered at community pharmacies around the country.
“You’re starting to see all sorts of changes in the healthcare system that take advantage of the convenience of the pharmacy, with the low cost of a pharmacy relative to a doctor’s office or hospital — and the whole process, I think, is driven by immunizations,” Mastromonica said. “It’s a high-touch [service]. It’s one-on-one in a room, where you’re talking privately about the patient’s health. That whole scenario makes people think of pharmacists differently than they did previously.”
Such pharmacy chains as Costco, Walgreens Boots Alliance, CVS Health, Rite Aid and Walmart have spent enormous time and capital to train and certify their pharmacists to deliver immunizations.
“Walgreens has 27,000 pharmacists, in addition to Healthcare Clinic nurse practitioners and physician assistants, who are certified to provide all CDC-recommended vaccinations, along with other healthcare services, such as blood-pressure testing,” said a company spokesman.
In addition, he said, “Walgreens works with employers and employer groups across the country to have our pharmacists administer flu shots at work site locations. By offering flexible schedules, we can reach the largest number of people and ensure they get vaccinated.”
According to the American Pharmacists Association, more than 200,000 of the nation’s roughly 300,000 practicing pharmacists are already certified to provide immunizations.
In a national survey of practicing pharmacists, APhA found that “the availability of immunizations in pharmacy practices has increased, with 8070 of practice sites offering immunizations on a walk-in basis, compared with 7770 in 2013.”
An expanding role in disease prevention
The positive impact that pharmacy-based immunization programs have had on preventive health efforts can hardly be overstated. With their ability to reach millions of Americans every day at retail pharmacy counters nationwide, drug, supermarket and mass merchandise chains have become the chief source for influenza vaccinations in the United States outside of doctors’ offices. And besides their widespread availability, those vaccinations also are significantly cheaper when delivered in a pharmacy: an average of $31 cheaper, according to one study.
Pharmacy retailers also collaborate with federal, state and local public health agencies, accountable care organizations and other entities to improve pandemic vaccine preparedness, noted NACDS president and CEO Steve Anderson. “Health authorities have credited pharmacies for improving the accessibility of immunizations, in times of public health emergencies and in meeting ongoing health needs,” he said. The goal, he added, is “to drive population health by leveraging and magnifying the success of accessible, pharmacy-based immunizations in collaboration with other healthcare professionals for the good of patients nationwide.”
In October, the Centers for Disease Control and Prevention commended the pharmacy profession for its efforts to advance immunizations through its pharmacist training and certification efforts. “Over the last 20 years, pharmacists have played an expanding role in reducing the risk of vaccine preventable illnesses,” wrote Anne Schuchat, assistant surgeon general and principal deputy director of the CDC.
A reputation for honesty, trustworthiness
In the nation’s hierarchy of most-trusted professions, where does the community pharmacist stand? Near the very top of the list.
Again in 2015, pharmacists ranked second only to nurses among all professions in Gallup’s annual Honesty and Ethics survey. That makes the 13th year in a row that Americans have ranked pharmacists among the top three of all professions in terms of trustworthiness and ethical standards.
The annual poll was conducted Dec. 2 to 6, 2015, with a random sample of 824 adults, ages 18 years and older, living in all 50 U.S. states and the District of Columbia. More than two-thirds of all respondents gave pharmacists “very high/high” marks for honesty and ethical dealings, slightly ahead of medical doctors, high school teachers and police officers.
“Nurses, pharmacists, medical doctors and high school teachers remain untarnished at the top,” according to the Gallup poll.
“The survey results reflect the remarkable trust that patients continue to place in their pharmacists, and for strong and important reasons,” said National Association of Chain Drug Stores president and CEO Steve Anderson. “Pharmacists are highly educated and highly accessible professionals. They are highly valued in neighborhoods across America, and particularly by those in the greatest need.”
In addition to the latest Gallup poll, “NACDS’ own opinion research shows another interesting finding: that those who have more first-hand experience with pharmacist-provided services feel even more strongly about their value,” Anderson added.
“These positive attitudes are translating into ever-stronger bipartisan support for pro-patient and pro-pharmacy initiatives in the U.S. Congress, as well as an expansion of the pharmacists’ scope of practice in the states,” added NACDS’ top executive.
Endorsing pharmacists as healthcare providers
“The positive, reverberating news about pharmacists marks a great beginning of the year for pharmacists, and gives well-deserved credit for the essential and expanding part they play as trusted healthcare providers, bridging gaps to care for the patients who need it most,” NACDS reported. “The professional validation comes at a time when pharmacists are positioned extraordinarily well to fill gaps in patient access to care.”
Indeed, national opinion surveys conducted on behalf of the pharmacy organization show that a large majority of Americans strongly embrace pharmacists’ expanding role as healthcare providers for a wide array of walk-in services.
The most recent such poll, conducted via the Internet among 1,000 informed likely voters in late July 2015, asked respondents whether they thought a pharmacy should be allowed to offer several types of health services, and whether they would seek out those services within a pharmacy. The results were eye-opening: 83% of respondents view pharmacies as appropriate settings for basic health services, and nearly 8-in-10 voters see them as a source for vaccinations and immunizations. More than 7-in-10 of those polled support the use of pharmacy-based primary healthcare clinics.
“There continues to be overwhelming support for allowing pharmacies to offer … new healthcare services, with notable increases since 2013,” according to the polling organization, Public Opinion Strategies.
A separate poll last year also showed strong support among Americans for legislation that would give pharmacists full status as healthcare providers, with 82% of those surveyed expressing support for provider status legislation.
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