By Jane Norman, CQ HealthBeat Associate Editor
October 26, 2012 -- The excess readmission of Medicare patients is strongly linked to patients’ difficulties with their prescription medications once they get home or are moved to a non hospital setting, says a new report by a national health policy research organization.
There are initiatives underway and models for change. Yet “there is much room for improvement and growth,” says the report by NEHI, an independent group formerly known as the New England Healthcare Institute. “Most hospitals have only just begun to confront the need to upgrade medication practices as part of their effort to reduce readmissions or face new government penalties.”
The problems are daunting and the system of medication management now is “fragmented and inconsistent,” says NEHI. When patients are admitted, hospital staff members struggle to put together accurate lists of their current medications. Some patients don’t have family members who can help manage their medications. And even when there are caregivers, they may be so overwhelmed by the patient’s hospital experience they may have difficulty comprehending directions for prescription use. Scheduling follow-up visits with doctors after discharge can be tough because doctors’ appointment schedules are packed.
The report says that nearly 20 percent of Medicare patients experience problems once they are discharged and must be readmitted. And readmissions are costly. The Medicare Payment Advisory Commission has estimated that each readmission costs $7,200 per case, says the report. Better management of meds is at the core of getting these numbers down, says NEHI.
In its “Thinking Outside the Pillbox” report, NEHI took a look at what’s known as medication adherence as hospitals begin to face penalties for too many patient readmissions.
Beginning this month, in line with requirements in the health care law (PL 111-148, PL 111-152), payments to hospitals will be reduced by up to one percent for excess readmissions for heart failure, heart attack and pneumonia.
By 2015, the maximum penalty will rise to three percent and the Centers for Medicare and Medicaid Services will be able to extend the penalty to other conditions, including chronic obstructive pulmonary disorder and certain cardiovascular procedures, according to the institute.
Managing medications correctly is essential to planning for discharges and providing care afterward. The report lists three givens. One is that adverse events, or negative changes in a patient’s health, are a major cause of avoidable health readmissions. The second is that most of these adverse events after discharge are related to prescription drugs. The third is that these events happen because, for one reason or another, the patient isn’t taking medications as prescribed.
It’s not hard to understand why difficulties develop as it’s laid out by NEHI. Years ago, doctors based in the community authorized a patient’s admission to the hospital, performed rounds and authorized the discharge. So the same provider was with the patient throughout the process.
Now, the cast of characters has grown and there are many patients with chronic conditions who see both primary care doctors and specialists, inside and outside the hospital. Hospitalists, or doctors who only work inside hospitals, see patients inside the hospital. If the patient goes home, the services of a visiting nurse may be required. Other patients instead go to long-term acute care hospitals or skilled nursing facilities. And on top of that, disease management advice may be provided to a patient over the phone on behalf of an insurance company.
Shorter hospital stays and complex conditions mean that patients after their discharge may need a lot of assistance. This all results in a need for much more communication and coordination among providers, says NEHI.
Team Care Could Help
New models of care are emerging and all involve health care teams, and share core attributes, says NEHI. There is one designated, accountable leader or manager on the team and there’s coordination among doctors, nurses, pharmacists and others.
Also needed are accurate lists of the prescriptions a patient was using prior to hospitalization, which can be difficult but are needed so that the patient can be given an explanation of the changes in medications as a result of the hospitalization. Without that explanation, the patient may not be clear on what drugs to use, potentially leading to adverse events.
The teams also need to talk with patients and their family members or other caregivers about the plan after discharge for medications and how they will fit into daily living, says NEHI. Patients who have just left the hospital may not be in the best condition to understand a drug regimen so communication with family members is key, says NEHI. And there should be follow up in the form of a home or office visit with a nurse or doctor soon after a patient is discharged.
NEHI also has advice for hospitals including:
- Greater and more effective use of electronic prescribing systems, to improve the accuracy of medication histories.
- Increased use after discharge of community nurses and pharmacists, and better communication among prescribing doctors or nurses and other providers.
- Advancements in patient engagement and counseling that stress the need for patients to manage their own medications.
- Improved use of technology to help with drug monitoring and reminders to patients who can’t cope on their own and don’t have family members or caregivers at hand.
The National Association of Chain Drug Stores Foundation applauded the NEHI report, saying that it highlights the role played by pharmacists in stemming hospital readmissions as well as use of teams that include pharmacists.
• Report on Medication Adherence (pdf)
Jane Norman can be reached at [email protected].