Medication reconciliation pilot pays dividends

CM interventions help reduce readmission rates

Following a successful pilot project that included interventions by an RN case manager, Capital BlueCross is exploring ways to roll out its medication reconciliation initiative throughout the health plan.

In the pilot, the participating Medicare Advantage members who were patients at one not-for-profit hospital in the insurer's network experienced a 30-day readmission rate of 8.6% compared with 15.5% for those who did not receive the interventions.

"We obtained those statistics by analyzing readmissions for all Medicare Advantage patients and did not target a specific diagnosis. All of our Medicare members who are hospitalized tend to have the same top chronic diseases," says Jennifer Chambers, MD, one of the Harrisburg, PA-based health plan's medical directors.

Members who were included in the pilot project were contacted telephonically by an RN case manager who compared medications they were taking before hospitalization to those they were taking after discharge, discussed their medication regimen, and empowered them to discuss any medication issues with their doctor.

Using the information it gained in the pilot, the health plan is working on plans to roll out a medication reconciliation program as part of a transition care initiative to hospitals and Medicare Advantage members throughout the 21-county area it covers.

"The pilot was very labor-intensive, and we knew from the get-go that the pilot is not something we can duplicate across the network, but we are applying the lessons learned from the pilot to work on solutions for the entire Medicare Advantage population," Chambers says.

In the pilot project, the case manager performed outreach calls in which she compared medications prescribed before and after discharge and educated the member on his or her medication regimen.

"Although it was more time-consuming than a typical outreach call, we recognized the value of the additional work and the benefits to the member. We are looking at ways to streamline the process and still get similar outcomes," Chambers says.

In addition to producing positive outcomes, the program generated referrals into Capital Blue Cross' case management and disease management programs.

Among the 70 patients who completed the reconciliation program in the pilot, 18 were referred for case management, social work, disease management, or depression management programs.

Here's how the program worked during the pilot project:

The health plan's concurrent review nurse who works on-site at the hospital collaborated with the hospital discharge planners and obtained the discharge orders, discharge instructions, admissions medication list, and list of discharge medications. She faxed the information to the health plan for review by a pharmacist.

The health plan's pharmacist examined the medication list, looking for dosage issues, incomplete medication sheets, missing medications for the targeted disease state, medications that didn't match the stated diagnosis, and diagnoses with no medication or medications with no corresponding diagnosis, as well as potential drug-drug interactions, Chambers says.

"The pharmacist also looked for any opportunity to benefit the member by lowering the medication costs, thereby improving compliance," Chambers says.

For instance, in some cases, the pharmacist might suggest a drug that combines an ACE inhibitor and a diuretic, saving the member money on copays.

The pharmacist forwarded the information to the discharge outreach nurse case manager who called the member and talked with him or her about the medication regimen.

"We found that the biggest issues revolved around incomplete or inaccurate information about medications the patient was taken when he or she was admitted to the hospital. Often patients don't know the name of their medication or they forget they are taking it. When the hospital doesn't have a good list to begin with, it's difficult to reconcile medications at discharge," she says.

During the phone call, the case manager asked the patients to get their prescription bottles out and read the names and dosages of the medication.

"Often members have drugs at home that they haven't discarded or they don't understand that they shouldn't still be taking a particular medication. In these cases, the case manager went over the medication with the members, told them it may be a problem medication, and urged them to take the medication with them when they visit their primary care physician," Chambers says.

If needed, the case manager facilitated the appointment with the doctor.

"In the pilot, we didn't encounter any life-threatening combination of medications or other issues. If we had, the case manager would have called the physician immediately," she says.

"Like all insurers, we have issues with medication reconciliation not being accurate and members being readmitted to the hospital as a result of it. We are looking at ways to address the problem and to tailor a solution to our membership," she says.

The health plan is analyzing data from the pilot and other research to identify particular patient populations that could best benefit from a medication reconciliation project.

"We know that patients with some conditions are more in need of this program than the entire Medicare population. At this point, it is unclear if we should be narrowing our focus to certain diagnoses within the Medicare population. As we gain more experience, we may be able to answer this question more accurately," Chambers says.

Although there is literature to support targeting certain diagnoses and age groups, the discharge transition is a problem for many patients, including Medicare and the commercial population, Chambers says.

Issues in transitions in care do not include medication reconciliation alone. The ability of patients to manage their health care issues and know where their resources are is a problem across the board, Chambers says.

"We are looking at where we can play a role in the process to discharge patients safely and reduce readmission rates. Medication reconciliation doesn't occur in isolation. It is part of a complex discharge planning process that includes ensuring that patients have follow-up appointments, that they understand what tests and procedures they have after discharge, and communicating the information to the primary care physician," she says.

"In the final analysis, when you look at whose job it is to ensure that medication is reconciled, it's the hospital's job and the primary care physician's job, but there is still a role for a clinical management program in an insurance company to play a role in discharge for the patient," she adds.

When patients have a successful discharge, receive follow-up care, fill their prescriptions for appropriate medicines, and follow their treatment regimen, it's a win-win situation for everyone, Chambers points out.