Cut readmissions through med adherence

Educate patients at risk for noncompliance

Good medication reconciliation is like the Holy Grail in healthcare. If only we could make sure that the old, sick, frail patients understand what they need to take, when and why, we could keep them from bouncing back to the hospital.

Vanderbilt hospitalist and researcher Amanda Salanitro, MD, is working on a six-hospital study that is designed find potential answers. Among the theories Salanitro has developed: improved and increased inpatient teaching to patients about their medication regimens, what has changed in them since they entered the hospital and what will be different when they get home. “But the thing is, discharge is a really confusing time, and the patients are already sick when they are with us. Even when they get home, they may not be at their normal baseline cognitive level. It can take up to a year to completely recover from an illness and hospitalization.”

What seems to work is a toolkit being used by the ongoing Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS), says Salanitro. It includes getting patients to “own” their medications. Point patients to the online templates available at the AHSP (http://www.ashp.org/menu/PracticePolicy/ResourceCenters/PatientSafety/MyMedicineListtrade.aspx).

Encourage providers to learn to take a good medication history, she says. The Society of Hospital Medicine has some good resources, including a video that can help, at http://www.hospitalmedicine.org/Content/NavigationMenu/QualityImprovement/QIResourceRooms2/MARQUIS/Medication_Reconcili.htm.

Risk stratify your patients. If they are taking one or two medications, they aren’t likely to be the problem. It is the frail, the elderly, and those on multiple medications, and patients on high-risk medications like warfarin or insulin who are most likely to have issues that could bring them back to the hospital. Pharmacists are often the best at taking medication histories. If you don’t have a lot of pharmacist resource, be sure to let them take on these riskier patients.

Use your marketing department to do community campaigns that encourage patients to bring in their medication lists and a bag with their actual medications in them.

Even if you do all of this, it may be hard to tell if what you are doing is working at keeping patients from unplanned readmissions. Salanitro says she did a systematic review last year looking at models that predict readmissions and none worked very well. “Medications have a small role. It’s not trivial, but it’s not the only thing,” she says. “If we play around with their medications while they are here and they don’t learn enough about the new regimen, they’re more likely to come back.”

Streamline the drug regimen

In Pittsburgh, Wheeling Hospital has created the “Seven or More” project, says Lisa Schatz, PharmD, BCPS, senior director of clinical services. Patients are screened, and those who are taking seven or more medications get a higher-level screening with a skilled pharmacist interviewer who can help determine if the patient is having trouble with what to take when or how much to take with what food and drink.

The pharmacist will look for ways to streamline or simplify the drug regimen, says Schatz. Since so many patients at the hospital come from nursing homes or are of an age when they might, providers make it a point to look more carefully at those patients. “We look to see if they are taking multiple drugs for the same indication. We look at the diagnoses, and whether the drugs they were prescribed actually work for the condition.”

Every drug has a monitoring parameter, Schatz says. “If they are on a blood pressure drug, take their BP. Is the drug working? Is it working too well?”

If it isn’t then find a way to eliminate the drug, change the dosage or combine it with another. These are things that a pharmacist is particularly trained to consider. “This isn’t something we decided to do because something triggered it, or something bad happened,” Schatz explains. “This is just good care.”

The Seven or More project just began, and although readmission rates are pretty low at 22%, they are hoping to see a reduction. “If you aren’t getting paid for them, then any improvement becomes important.”

Wheeling is ramping up patient teaching, too, providing both teach-back style sessions and written information, including calendars for complex cases. “Patient understanding can be hard to measure, but if we get them to say it out loud and they have it in writing, it can help us verify that they understand what we have explained.”

The medical record reinforces the need to teach about new medications by including it on a nurse task list if a new medication is added. “The objective is that as soon as something is prescribed, the nurse teaches. On discharge, we have a retail pharmacy on site — open until midnight daily — so that the pharmacist can deliver medications for home use and do some more teaching.” A pharmacist is in the ED until midnight, too.

Lastly, patients are phoned post-discharge to see if they have any questions. “It’s good business and good care,” says Schatz.

For more information on this topic, contact:

  • Amanda Salanitro, MD, Vanderbilt University, Nashville, TN. Telephone: (615) 936-3710.
  • Lisa Schatz, Pharm.D., BCPS, Senior Director of Clinical Services, Wheeling Hospital, Pittsburgh, PA. Telephone: (412) 749-1070.