Published in the April 2012 issue of Today’s Hospitalist
FERNANDO PETRY, DO, who directs the six-physician hospitalist service at St. Lucie Medical Center in Port St. Lucie, Fla., has a pretty good handle on why patients bounce back after discharge. But until recently, he and his colleagues were particularly frustrated over one leading (and potentially preventable) culprit in high readmission rates: poor medication adherence.
“Many patients we readmit come back because they were not able to pick up the antibiotic we prescribed,” says Dr. Petry. “Or they failed outpatient heart failure management because they did not have their prescription for Lasix filled, or they were not able to pick up an increased dose from the pharmacy.”
When the problem finally hit the radar of administrators and case managers at the 229-bed facility, which is part of HCA’s East Florida division, the hospital decided to tackle it head-on. Instead of waiting “often futilely ” for patients to fill their prescriptions, the hospital decided to bring the medications to patients. As part of an ongoing collaboration between HCA and the national Walgreens pharmacy chain, pharmacists at one nearby retail Walgreens fill the discharge prescriptions. A pharmacy tech then delivers the medications to patients before they leave the hospital.
It is too soon to say whether the year-old program has cut 30-day readmission rates, Dr. Petry explains. But he and his fellow hospitalists are confident that getting medications to patients before they leave the hospital certainly benefits both patients and their families.
“This service obviously improves compliance,” Dr. Petry says, “and it helps with the issue of patients not knowing which medications to take and which to stop.”
Hospitalists report that they’re receiving fewer calls from patients who forgot to take their prescriptions or lost them, and from pharmacists asking about refills. “In that regard,” he adds, “it’s been a real time-saver.”
Hands-on approach at the bedside
Here’s how the program works. After the hospitalist prescribes discharge medications, the charge nurse or clinical nurse leader on the unit contacts Walgreens, and a pharmacy tech comes to the hospital to pick up the prescriptions to be filled. The technician meets the patient in the room, verifies allergies and any other pertinent information, and then returns to the pharmacy.
The Walgreens pharmacist who fills those prescriptions is available by phone for patient consultation. The pharmacy tech then delivers the prescriptions and educates the patient about the new medications and possible side effects, explaining how new drugs might interact with others the patient is already taking. While hospitalists still conduct the initial education that patients receive about their hospital prescriptions, Dr. Petry notes, the pharmacy education serves as a valuable add-on.
“A lot of the time, patients are not listening or they’re distracted when we educate them the first time,” he says. “Now, we feel that there’s someone to back us up.”
As a general rule, the hospitalists write for (and Walgreens fills) a 30-day supply, although that varies depending on the medication. According to Dr. Petry, the hospital wants to make sure that patients get enough doses so they won’t need to come back to the emergency room in a week. At the same time, they don’t want to give patients such a large supply that patients are tempted to forego a follow-up appointment with their primary care physician.
Another advantage of the program is that Walgreens handles any insurance coverage or authorization problems that emerge before patients are discharged. When needed, hospital staff works with the retail pharmacists on those issues.
The initiative has been successful enough that HCA and Walgreens have rolled the program out to other hospitals in the East Florida division, including Lawnwood Regional Medical Center in Fort Pierce, Fla., where Dr. Petry also oversees four hospitalists. The Walgreens collaboration, he says, is one of a number of national initiatives that the for-profit hospital chain is actively involved in to cut down on preventable bouncebacks.
Not a cure-all
While the program has been effective, it has its limitations. The major obstacle is that not all patients have insurance coverage or the resources to pay for medications, so the service may not be available to them. In such cases, the hospital continues to work with pharmaceutical companies, foundations or local ministries to help patients get the medications they need. Sometimes, those prescriptions can also be delivered to the hospital.
Problems with lack of insurance are on the rise because the facility’s demographics are changing “and quickly. According to Dr. Petry, the hospital is caring for a growing number of uninsured patients, and many patients are younger than they have been in the past.
Elderly, chronically ill patients with COPD, heart failure and myocardial infarction still constitute the majority of inpatients (and many of the hospital’s readmissions), as the hospital’s catchment area encompasses six nursing homes and a large number of retirees. But these days, St. Lucie is treating more middle-aged patients who lack insurance and who are both chronically ill and under-managed in terms of their chronic condition.
In addition, many younger patients who are uninsured also suffer from chronic alcohol or drug abuse; Dr. Petry suspects that’s due in part to the region’s high unemployment rates. The problem with chronic alcoholism is so serious, he notes, that one HCA facility in West Palm Beach “recently opened a unit specifically to help with those readmissions.”
In addition, many patients the hospitalists care for ” across all age groups “now have chronic infections or are experiencing difficulties with dialysis. Those are issues, Dr. Petry points out, that a retail pharmacy program clearly cannot address.
“This definitely isn’t a cure-all, and we know it won’t prevent readmissions with certain types of patients,” he says. “But our view is that every little bit counts. If we can reduce readmissions by 1% to 2% on any level with any diagnosis, that will help us out. And Walgreens is streamlining discharge and making our hospitalists’ lives easier.”
Bonnie Darves is a freelance health care writer based in Seattle.