Collaborative Endeavor Aims to Tackle Hospital Readmissions

An ongoing problem that plagues both patients and health care providers is the rate of readmission of patients. For those dealing with chronic diseases or a combination of health issues, hospital readmission can be costly, both for the patient and the hospital, and is a factor in poor health outcomes.

To address this issue, a team of investigators with the Auburn University Harrison College of Pharmacy and East Alabama Health is collaborating to research readmission rates and solutions for improving the transition of  care process.

Headed by Dr. Kimberly Braxton Lloyd, associate dean for clinical affairs and outreach, and Dr. Courtney Gamston, an ambulatory care clinician within the Auburn University Pharmaceutical Care Center, the interprofessional team is supported by a $683,910 grant from the Food and Drug Administration’s Center for Drug Use and Evaluation’s Safe Use Initiative.

Front row (left to right): Matthews, Ledbetter, Latham, Zmajevac, Lee and Westrick. Back row: Beams, Peden, Johnson, Gamston, Patterson, Waites and Braxton Lloyd.

Early hospital readmission is a significant issue in health care, accounting for more than $17 billion in health care spending each year, and is commonly caused by patient disengagement and noncompliance with the discharge care plan.

“Approximately 14% of patients are readmitted to the hospital within 30 days of discharge, often due to preventable medication-related issues,” said Braxton Lloyd. “This research seeks to develop a model for the provision of post-discharge support that is not only effective but feasible and sustainable in real-world settings.”

To address the problem, the team is in the midst of a two-year project titled “Assessment of a pharmacist-led interprofessional transitions of care program targeting patients with multiple recent hospital admissions: the ICARE Program.” The goal of the project is to improve the care of patients by identifying and addressing medication-related problems and barriers    to care in order to decrease the rate of  hospital readmission.

“This is my favorite type of research because it is specifically focused on improving the care of patients and provides a real-world look at strategies to do so,” said Gamston. “In one project, we have both implemented a service that is helping our community while also generating data that can be shared with other health systems to help them to do the same.”

The Harrison College of Pharmacy (HCOP), is fortunate to have a partner like Health/East Alabama Medical Center (EAMC) nearby and willing to collaborate.
“AU and EAMC have successfully partnered in many ways over the years to enhance patient care services through collaborative outreach and research and are both committed to advancing this partnership,” said Braxton Lloyd.

The idea for the project came from a former program within the College of Pharmacy in which teams of students were assigned patients within the community they would meet with regularly to discuss their health. Dr. Braxton Lloyd and her team of students had a patient on referral from EAMC with a complex medical condition and multiple hospital admissions per year.

“Through months of personalized care that included securing access to needed medications and working with insurance and patient assistance programs, the HCOP team was able to help the patient manage their care and reduced annual admissions by 75 percent,” said Gamston. “EAMC recognized the opportunity to decrease admissions for a broader population of patients through a collaborative transitions of care effort.”

After reviewing a list of 20 patients from EAMC with a history of frequent hospital admissions, Gamston and Braxton Lloyd put together a proposal and received funding from the FDA to study and implement a plan.

Along with collaborating with professionals at EAMC, the project also benefits from the diverse experience within HCOP’s Division of Clinical Affairs and Outreach and Department of Health Outcomes Research and Policy.

“HCOP faculty and staff bring innovative solutions to real-world problems that are often seen in health care,” said Braxton Lloyd. “Our faculty and staff have advanced training in research design and statistics and provide a structured approach to continuous quality improvement and outcomes evaluation that is needed for decision making. Thus, our partnership with EAMC is synergistic as we work together to develop sustainable service models that improve patient outcomes.”

For the study, the team identified patients who have been admitted to the hospital at least three times in the last year and/or have heart failure and were discharged back into the community setting. Patients were chosen for the high risk of readmission to the hospital following discharge because of the complex nature of their medical conditions and treatments. Along with the conditions themselves, patients also typically have other associated challenges, such as multiple daily medicines, lack of transportation, need for financial assistance and poor access to adequate nutrition.

As part of the transitions of care program, a pharmacist follows up with the patient four times within 28 days of discharge for reminders and assessment of medication-taking and self-care behaviors while also evaluating signs  and symptoms indicating the need for  additional care.

A social worker also contacts each patient by phone to evaluate social risks and the need for linkage to community resources, including transportation, food bank and other nutrition services, patient assistance programs and any others that may come up.

A little more than a year into the program, the team is seeing significant improvement and a reduction in readmission rates.

“We have consistently found that, when patients who are at high risk for readmission are discharged into the community setting and participate in at least one outpatient visit with our care team, their risk for being readmitted  to the hospital within 30 days is nearly cut  into half compared to those who enroll in the  service but never complete an outpatient visit,”  said Gamston.

Through the process, the team also found that for patients who are discharged on a medication regimen that is different from what they were on prior to admission, there is a large risk for medication errors due to miscommunication, misunderstanding and barriers to obtaining their new medications. To account for this, they found the need to visit patients at their homes to review medications, including identifying old prescriptions that should be discontinued.

“In just over a year, the incredible need for this service has been highlighted and we have seen that the addition of post-discharge support is instrumental in decreasing the likelihood of early hospital readmission,” said Braxton Lloyd. “Working as a team, the pharmacist, social worker and other health care providers are able to improve appropriate use of medications, identify and resolve barriers to care and address social determinants of health, which leads to improved overall patient health.”

With the data and information, they are compiling, the team hopes to support this service at EAMC while also establishing a model that can be used in other hospital systems and facilities around the country, improving care and health outcomes.

“This data further shows the vital role that pharmacists and social workers can play as part of the care team and how current practice models can be advanced in a variety of patient populations to take advantage of their expertise,” said Gamston.

The work would not be possible without a diverse interprofessional team tackling the problem from all angles.

Braxton Lloyd and Gamston are the project investigators with Braxton Lloyd serving as senior project investigator. Dr. Mafe Zmajevac is the transitions of care pharmacist in charge of the day-to-day operations of the program while Danielle Waites, a patient care coordinator within HCOP, handles the outpatient engagement as a social worker. Dr. Greg Peden, executive director of clinical health services, and Paige Patterson, assistant director of business operations, oversee the project’s financial and health systems information technology aspects.

Adding perspective from a health outcomes point of view, Drs. Jingjing Qian and Salisa Westrick, faculty members in HCOP’s Department of Health Outcomes Research and Policy, oversee the assessment of service implementation and service outcomes.

On the EAMC side, the project is supported by Dr. Chuck Beams, chief pharmacy officer; Sutricia Johnson, director of case management; Laura Matthews, director of inpatient pharmacy services; Leborah Lee, clinical pharmacy manager; Kara Latham, pharmacy operations manager; Laura Rainey, manager of care coordination; Stefanie Ledbetter, director of clinical research and quality; and Will Ansick, clinical informatics specialist.

“When you improve the health of an individual, you improve the health of the community,” said Gamston. “Lowering readmission rates helps to keep people at home and healthy longer and decreases the number of people that need to be cared for at one time at the hospital, leading to lower health care spending for both the patient and health care system.”