Abstract
To reduce readmission rates and avoid financial penalties from the Centers for Medicare and Medicaid Services, hospitals are seeking to implement innovative transitions of care (TOC) programs. This retrospective study evaluated the Discharge Companion Program (DCP), a pharmacist- and nurse-coordinated interprofessional, collaborative TOC program. Adult patients (18 years and older) from a single hospital, discharged with at least one qualifying diagnosis, were eligible for this service. The hospital transitional care coordinator nurse referred qualified patients to the DCP nurse coordinator, who scheduled telephonic medication therapy management (MTM) reviews with the DCP pharmacist at one- and three-weeks postdischarge. Hospital records and DCP documentation were reviewed to describe respective interventions and assess the impact on 30-day readmissions. A total of 456 patients were referred to the DCP between 31 August, 2015 and 7 September, 2016. Of the 340 patients who participated (DCP group), 44 (13%) compared to 17% (n = 20) of the usual care, were readmitted within 30-days postdischarge. The DCP pharmacists conducted 1242 clinical interventions with participants, demonstrating the benefits of an interprofessional TOC model involving multiple, pharmacist-delivered MTM intervention touchpoints within 30 days post-hospital discharge.
Highlights
One in five patients are readmitted post-hospitalization [1]
While other characteristics including gender, race, ethnicity, qualifying health conditions, and discharge location were similar between the two groups, Discharge Companion Program (DCP) participants received consultation from a hospital transitional care coordinator nurse significantly more often than the UC group (p < 0.01)
The DCP pharmacist provided a wide variety of clinical interventions, with the majority related to improving medication safety (53%) and adherence to treatment guidelines for medications and vaccines (43%)
Summary
One in five patients are readmitted post-hospitalization [1]. Hospital readmissions are associated with worsened health outcomes for patients and increased healthcare expenditures [2].While some readmissions are unavoidable, research suggests that collaborative activities including enhanced patient education, coordination with post-acute care outpatient providers, and reducing medical complications during the patients’ initial hospital stays can prevent readmissions [1].Reducing readmissions among Medicare beneficiaries is a high priority for the Centers for Medicare and Medicaid Services (CMS), the largest healthcare payer in the United States (US). One in five patients are readmitted post-hospitalization [1]. Hospital readmissions are associated with worsened health outcomes for patients and increased healthcare expenditures [2]. While some readmissions are unavoidable, research suggests that collaborative activities including enhanced patient education, coordination with post-acute care outpatient providers, and reducing medical complications during the patients’ initial hospital stays can prevent readmissions [1]. CMS created the Hospital Readmission Reduction Program (HRRP) to incentivize hospitals to reduce readmission rates [3]. The HRRP financially penalizes hospitals with higher-than-average 30-day readmission rates for select conditions including: myocardial infarction (MI); heart failure; pneumonia; chronic obstructive pulmonary disease (COPD); elective hip or knee replacement; and coronary artery
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