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Service Delivery Innovation Profile

Hospital–Retail Pharmacy Partnership Provides Inhospital and Postdischarge Support to At-Risk Patients, Leading to Fewer Readmissions and High Patient Satisfaction


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Snapshot

Summary

In partnership with Walgreens, Washington Adventist Hospital provides inhospital and postdischarge support to patients at high risk of readmission. Known as WellTransitions®, this program provides a comprehensive list of all active medications to hospital staff (to support medication reconciliation), a predischarge pharmacist review of the medication regimen to identify duplicative and unnecessary medications and to better align refill dates, bedside delivery of all newly prescribed medications before discharge, and inhospital and postdischarge telephone-based patient education and support from a pharmacist. The program has allowed the hospital to identify and address multiple challenges facing at-risk patients after discharge, has contributed to a meaningful decline in readmissions among high-risk patients, and has generated high levels of patient satisfaction.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of 30-day readmissions rates among high-risk patients, along with post-implementation data on patient satisfaction with the program and the number of patients the program has assisted with post-discharge challenges.
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Developing Organizations

Walgreens; Washington Adventist Hospital
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Use By Other Organizations

Walgreens has similar partnerships in place with a number of other hospitals, including Sarasota Memorial Health Care System in Sarasota, FL, and Marion General Hospital in Marion, IN.

Date First Implemented

2011
The bedside delivery component commenced in June 2011, and the remainder of the program began in May 2012.

Problem Addressed

At-risk patients (particularly older adults) who are discharged from the hospital often have difficulty making the transition home, due in part to difficulties adjusting to new (often unpredictable) circumstances created by their recent health issues and hospital stay. Many problems stem from a failure to understand and manage complex medication regimens and an inability to access followup care and support. As a result, these patients face increased risk of costly complications, readmissions, and death.
  • Complex needs, but little knowledge of how to manage them: At-risk patients discharged to home health or community-based care frequently have multiple comorbid conditions, and in many cases they or their caregivers have not been adequately educated on how to manage them or to participate in coordinating needed care. As a result, these patients often fail to adhere to their medication regimens (including filling prescriptions), as they do not understand them or the importance of taking medications appropriately.1 In addition, they may not arrange for needed followup care, or may face difficulties accessing such care.
  • Leading to costly readmissions: Almost 20 percent of Medicare beneficiaries end up being readmitted to the hospital within 30 days of discharge, and 34 percent get readmitted within 90 days. Two-thirds of patients discharged with medical conditions and more than one-half (52 percent) of those discharged after surgical procedures are readmitted or die within 1 year of the initial discharge.2 The average readmission for an older adult costs $7,400,2 and preventable readmissions cost the nation as a whole approximately $25 billion per year.3 Many readmissions stem from inadequate preparation and followup care, which makes patients vulnerable to medication errors, exacerbations of symptoms, and other problems that commonly result in readmission.4 For example, one study found that half of older patients readmitted to the hospital within 30 days of a previous discharge had not seen a physician between the time of the initial discharge and the readmission.5

What They Did

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Description of the Innovative Activity

In partnership with Walgreens, Washington Adventist Hospital provides inhospital and postdischarge support to patients at high risk of readmission. Known as WellTransitions®, this program provides a comprehensive list of all active medications to hospital staff (to support medication reconciliation), a predischarge pharmacist review of the medication regimen to identify duplicative and unnecessary medications and to better align refill dates, bedside delivery of all newly prescribed medications, and inhospital and postdischarge telephone-based education and support for patients from a pharmacist. Key program elements are outlined below:
  • Identification of eligible patients: Inpatient nurse case managers and social workers review information available on the hospital’s Web-based care management system to identify newly admitted patients who are at high risk of readmission after discharge to a community setting. The program does not serve those being discharged to skilled nursing and long-term care facilities, hospice care, or other institutional settings. In general, high-risk patients include those who have experienced a heart attack or who have congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), pneumonia, or other chronic conditions that put them at risk. In addition, patients experiencing end-of-life issues, those taking multiple medications, and those with active symptoms of a diagnosed behavioral health issue qualify for program services. Nurses and social workers designate eligible individuals as “managed” patients, meaning they qualify for WellTransitions® and general case management services provided by the hospital. Walgreens staff have access to the Web-based system and hence know when a patient has been designated as eligible.
  • Active medication list and pharmacist review to support reconciliation: Once a patient has been identified, Walgreens provides the hospital with the patient’s active medication list, which includes all prescriptions filled in the past year at any pharmacy. Walgreens contracts with an outside company to provide information on prescriptions filled elsewhere. Hospital-based staff use this information to inform the medication reconciliation process. For patients taking multiple medications, a Walgreens pharmacist reviews the list to look for opportunities to simplify the medication regimen by eliminating duplicate and unnecessary medications and addressing any discrepancies in fill dates. Using the Web-based system, the pharmacist communicates his or her recommendations to address these issues to the attending physician. As necessary, the pharmacist and physicians communicate through the system to come to agreement on any needed changes.
  • Bedside delivery and brief pharmacist consultation (available to all patients): The hospital offers day-of-discharge bedside delivery of newly prescribed medications and a brief pharmacist consultation to any patient identified by the prescribing physician as potentially benefiting from such services (including but not limited to those eligible for WellTransitions®). This process works as follows:
    • Requesting service: Using a four-digit telephone code, the prescribing physician or a nurse contacts either of two Walgreens pharmacy technicians who work in the hospital during regular working hours on weekdays.
    • Enrolling interested patients: The technician meets with the patient to explain the benefits of the bedside delivery program, enrolls interested patients, and faxes relevant information (including insurance status) to the local Walgreens store, which then fills the prescriptions.
    • Bedside delivery and brief pharmacist consultation: On the day of discharge, the technician delivers the medications to the patient’s bedside. Currently, Walgreens delivers more than 700 prescriptions per month to Washington Adventist patients through this initiative. While still at the bedside, the technician calls a Walgreens-based pharmacist, who engages in a brief telephone-based counseling session with the patient. The pharmacist explains any new medications that have been prescribed, including why the patient needs to take them, how to do so, and any anticipated side effects. The pharmacist also answers any questions the patient may have about the medication regimen.
  • Postdischarge telephone support: As outlined below, those eligible for WellTransitions® receive three or more postdischarge telephone calls from the pharmacist, with the typical call lasting roughly 10 minutes. As appropriate, the patient’s caregiver may also participate in the conversation. After each call, the pharmacist highlights any identified issues (e.g., the need to schedule a followup appointment or connect the patient to a smoking cessation program) in the Web-based care management system, thus allowing hospital-based case managers to address the issue.
    • Initial call within a few days of discharge: Conducted 2 or 3 days after discharge, the first call focuses on condition-specific clinical issues, with the pharmacist asking questions to gauge medication adherence and ensure the patient engages in appropriate self-management activities. For example, for CHF patients, the pharmacist will emphasize the need for the patient to weigh himself or herself every day and to report any unusual fluctuations in weight to the doctor. The pharmacist also makes sure the patient has scheduled needed followup visits, including with his or her primary care physician. The call also provides an opportunity to discuss any side effects the patient may be experiencing and to reinforce the need to follow appropriate lifestyle behaviors (e.g., diet, physical activity).
    • Followup roughly 10 days after discharge: The second call continues the discussion of issues covered in the initial call, including medication adherence, side effects, and verifying the scheduling of and attendance at followup appointments. The call also provides an opportunity to discuss other services the patient may need or be interested in accessing, such as smoking cessation programs.
    • Check-in call around day 25: This call generally focuses on medication adherence, including how the patient wants to handle prescription refills. As part of the call, the pharmacist gives the patient the opportunity to transfer prescriptions to another pharmacy or remain with Walgreens.
    • Additional as-needed calls and 24-hour support line: Pharmacists can schedule additional telephone consultations with the patient if they deem such calls to be appropriate. In some situations, pharmacists may sense that something is not right with the patient and hence want to check in more frequently. Walgreens pharmacists are also available around the clock to answer questions from patients and caregivers by telephone or online.

Context of the Innovation

Opened in 1907, Washington Adventist Hospital is a 252-bed acute-care facility located in Takoma Park, MD. The hospital has a large cardiac center that performs more than 500 open-heart surgeries and more than 6,000 catheterizations each year. The hospital is currently building a new facility in its primary service area, roughly six miles from the existing hospital. 

The impetus for this program began in April 2011, when the hospital’s director of case management became familiar with the Walgreens bedside delivery program at a conference. After the conference, the director approached senior executives at the hospital about adapting the program locally. Because Washington Adventist does not have an outpatient pharmacy, key stakeholders within the institution strongly supported the concept, seeing bedside delivery as a way to enhance medication compliance, reduce readmissions, and boost patient satisfaction (because recently discharged patients would no longer have to make a special stop to pick up their prescriptions). Launched in June 2011, the bedside delivery program quickly began paying dividends.

Early in 2012, hospital leaders began focusing more attention on the issue of readmissions, as major payers, including Medicare and the state of Maryland, were in the midst of discussing changes to payment policies to encourage hospitals to prevent avoidable readmissions. Consequently, hospital leaders began looking for ways to reduce readmissions, and were receptive when Walgreens representatives introduced WellTransitions® as a strategy for doing so.

Did It Work?

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Results

The program has allowed the hospital to identify and address multiple challenges facing at-risk patients after discharge, has contributed to a meaningful decline in readmissions among high-risk patients, and has generated high levels of patient satisfaction.
  • Multiple challenges identified and addressed: Several common challenges surfaced in a review of the first 48 patients served by the program, including 4 CHF patients who were not weighing themselves each day (in one case because the patient did not have a scale) and 7 patients without a followup primary care appointment. In each case, hospital case management staff intervened to address these challenges. In response to these findings and other issues, the hospital launched a transitional care program in February 2013. As part of this initiative, a designated nurse and social worker ensure that all at-risk patients leave the hospital with a scheduled followup primary care appointment.
  • Fewer readmissions: Since implementation of the program, the 30-day readmission rate for at-risk patients has fallen from 11 percent to under 7 percent, with only 3 of the first 48 high-risk patients served by the program being readmitted. Program leaders believe the WellTransitions® program has been a significant factor in this decline.
  • High patient satisfaction: All 48 patients rated their satisfaction with the program as a “4” or a “5” on a five-point scale. Anecdotally, patients report getting tremendous value out of their conversations with the pharmacists and appreciate the program’s ability to connect them to needed services.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of 30-day readmissions rates among high-risk patients, along with post-implementation data on patient satisfaction with the program and the number of patients the program has assisted with post-discharge challenges.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Introducing and adapting WellTransitions® services: Representatives from Walgreens met with hospital administrators and the case management team to explain WellTransitions® and how it can help reduce readmissions and enhance customer service. Once the decision to add the service was made, Walgreens and hospital staff worked over a period of several months to formalize the partnership and to customize program services to the unique needs of Washington Adventist patients. For example, at the hospital’s request, Walgreens agreed to give the pharmacist the option to suggest and conduct additional followup telephone calls (beyond the three established ones).
  • Introducing program to clinicians: The director of case management met with hospitalists and unit-based staff to explain the program and its benefits, positioning it as an additional resource for a specific group of patients at high risk of readmission.
  • Inservice training before launch of bedside delivery: As noted, the bedside delivery program began in June 2011. Before its launch, Walgreen representatives held several inservice training sessions for unit nurses to explain how the program worked.

Resources Used and Skills Needed

  • Staffing: Washington Adventist did not hire additional personnel for this program, as existing staff incorporate program-related activities into their regular job responsibilities. As noted, Walgreens has two pharmacy technicians onsite at the hospital Monday through Friday during regular working hours. In addition, pharmacists at a local store handle all telephone consultations with patients, both in the hospital and after discharge.
  • Costs: Walgreens does not charge the hospital for the bedside delivery program. Washington Adventist pays Walgreens a flat fee for every patient enrolled in WellTransitions®. Other hospitals have negotiated shared-savings arrangements with Walgreens, with both parties sharing in the cost savings generated by the program, as determined by an analysis using a mutually agreed-to methodology.
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Funding Sources

Washington Adventist Hospital
Washington Adventist pays for WellTransitions® out of an existing budget for post-acute resources. Third-party payers generally do not pay for services offered under this program, although most do pay for the postdischarge medications prescribed by physicians. Washington Adventist participates in the Federal 340B Drug Pricing Program, which provides access to reduced-price prescription drugs to health care facilities certified by the U.S. Department of Health and Human Services as "covered entities." This program gives the hospital access to additional funds to help defray the costs of providing medications to the uninsured and underinsured. More information is available at: http://www.hrsa.gov/opa/programrequirements/index.html.end fs

Tools and Other Resources

More information on this program is available at: http://www.walgreens.com/healthcare/business/ProductOffering.jsp?id=wellTransitions.

Adoption Considerations

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Getting Started with This Innovation

  • Identify and leverage program champions: Successful implementation depends on having one or more champions within the hospital sell the program’s benefits to key stakeholders, including hospital administrators, physicians, and nurses.
  • Determine appropriate metrics and set up tracking system: From the outset, program leaders should identify the key metrics that will be used to evaluate the program, such as readmissions, patient satisfaction, and costs. Systems should be put in place to collect and analyze the data needed to document the impact in these areas.

Sustaining This Innovation

  • Share data on program impact, including testimonials: Programs that demonstrate success become sustainable. Consequently, program leaders should regularly share evidence of the program’s impact with key stakeholders. Patient and staff testimonials about the program can often be more powerful than quantitative data.
  • Communicate regularly with vendor: In any partnership, the parties involved must establish and maintain open lines of communication so that any issues that arise can be resolved in a timely manner.
  • Incorporate additional resources into discharge plan: This kind of program can be of great benefit, but it does not represent the complete solution to preventing avoidable readmissions. Many high-risk patients need additional resources, such as community case management and adult day care.

Use By Other Organizations

Walgreens has similar partnerships in place with a number of other hospitals, including Sarasota Memorial Health Care System in Sarasota, FL, and Marion General Hospital in Marion, IN.

More Information

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Contact the Innovator

Judith Kurtis, LCSW-C, ACM
Director of Case Management
Washington Adventist Hospital
7600 Carroll Avenue
Takoma Park, MD 20912
(301) 891-6395
E-mail: jkurtis@adventisthealthcare.com

Innovator Disclosures

Ms. Kurtis reported having no financial interests or business/professional affiliations relevant to the work described in the profile; information on funders is available in the Funding Sources section.

References/Related Articles

Walgreens Newsroom. Walgreens WellTransitions® provides discharge services to help hospitals and health systems reduce readmissions. Available at: http://news.walgreens.com/article_display.cfm?article_id=5648.

Footnotes

1 The Joint Commission. Patient handoffs: making the hospital to home care transition. The Joint Commission Perspectives on Patient Safety. 2008;8(1):1-4.
2 Friedman B, Basu J. The rate and cost of hospital readmissions for preventable conditions. Med Care Res Rev. 2004;61(2):225-40. [PubMed]
3 Pricewaterhouse Coopers’ Health Research Institute. The price of excess: identifying waste in healthcare spending. Available at: http://www.pwc.com/us/en/healthcare/publications/the-price-of-excess.jhtml.
4 Coleman EA, Parry C, Chalmers S, et al. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-8. [PubMed]
5 Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-28. [PubMed]
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Original publication: December 18, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: December 18, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.