When a patient moves from an inpatient facility like a hospital to an outpatient or community setting, a ″transition of care″ occurs. During this time, pharmacists have the opportunity to step in and make a big difference in health outcomes—and profit for their pharmacy.
The reason lies in the problem of hospital readmission rates. When a patient gets readmitted to the hospital within 30 days of discharge, it’s an indication that something might have gone wrong in their transition back home. That leads to a worse health outcome for them, plus more healthcare costs for the insurer.
To discourage unplanned hospital readmissions, the Affordable Care Act of 2012 introduced the Hospital Readmissions Reduction Program, which penalizes hospitals for unplanned readmissions by reducing Medicare reimbursements—creating a pain point for hospitals and an opportunity for pharmacies.
To help hospitals keep their readmission rates down, pharmacies can step in to provide patient care and counseling that will prevent unnecessary readmissions. ″These transitions are really crucial to patients’ recovery and ability to maintain health without inpatient care,″ said Carlie Traylor, director of strategic initiatives and student affairs at NCPA. ″Ultimately, medication reconciliation will be the main star and why the pharmacy is part of this conversation.″
What is transitions of care?
The counseling and services entailed in a transitions of care program will vary based on each pharmacy’s business, but most programs include a medication reconciliation session immediately after the patient is discharged as well as regular check-in sessions for at least a month.
Coming from an ambulatory care background, pharmacist and owner of Lily’s Pharmacy Jennifer Shannon always knew she would provide transitions of care services when she opened her own practice in Johns Creek, Georgia. When patients are discharged from the local hospital, they have the choice to opt into Lily’s transitions of care program.
″We have remote capabilities during their inpatient stay, so as soon as they opt in, I can log into the EMR system for the hospital and monitor changes throughout their stay,″ Shannon said. ″Then, when they are discharged, the pharmacy already knows the full picture.″
The access to EMR is a massive help, Shannon says, because it closes an information gap between the hospital and pharmacy. The pharmacy knows exactly what prescriptions should have been prescribed as well as any medications that may have been discontinued.
Then, they sit down with the patients to do a medication reconciliation. They go over medication history, how patients are taking them, and how they are tolerating them. The pharmacy collaborates with the hospital physicians to make any necessary changes. After the initial appointment, they follow up with the patients on day three after discharge, day seven, day fourteen, and then monthly thereafter.
Lily’s also goes the extra mile for patients by helping them coordinate their follow-up appointments. ″So often I’ll ask, ‘When’s your cardiology appointment?’ and they don’t have one scheduled,″ Shannon said. The pharmacy also steps in to prevent patients from going to the emergency room because they’ve run out of medication. If a patient has 30 days of meds but their appointment isn’t for another 38 days, the pharmacy will call the inpatient doctor to see if they can extend the prescription so they don’t run out before their follow-up. ″These simple five-minute phone calls from the pharmacist can really save a life,″ Shannon said.
Richard Logan and Tripp Logan, owners of L & S Pharmacy in Charleston, Missouri, first introduced their transitions of care program around 10 years ago. The transition from hospital to home is the first step in a longitudinal care program that helps patients maintain their health long after their discharge.
When they leave the hospital, patients can receive medication optimization services and counseling sessions with a pharmacist, but the intervention doesn’t end there. After receiving an initial consult, a patient may be enrolled in a care coordination program. This includes chronic care management services, in which the pharmacy coordinates with primary care providers to help patients set monthly goals related to their health. They also have condition-specific programs like blood pressure training to help patients better understand their condition.
″Really these services ensure patients don’t go to the hospital in the next five years, not just in the next 30 days,″ Tripp Logan explained.
The Hospital Readmissions Program
The Hospital Readmissions Reduction Program is a provision of the Affordable Care Act of 2012 that requires the Centers for Medicare & Medicaid Services to penalize hospitals that have excess readmissions within 30 days. It links reimbursements to readmissions—when a hospital has an unplanned readmission, they have to pay a penalty. The intent of the program is to incentivize better communication and care coordination after patients are discharged from the hospital.
The HRRP includes six specific conditions and procedures as part of its 30-day risk-standardized unplanned readmission measures, which include:
- Acute myocardial infarction
- Chronic obstructive pulmonary disease
- Heart failure
- Coronary bypass graft surgery
- Elective primary total hip arthroplasty and/or total knee arthroplasty More conditions and procedures may be added in the future.
The HRRP creates space for pharmacies to offer much needed transitions of care services. By involving pharmacies, discharged patients will get more attentive care that leads to better health outcomes, and in turn, hospitals will get a higher reimbursement.
A profitable partnership?
A transitions of care program isn’t only good for the hospital’s bottom line—it’s good for the pharmacy’s bottom line, too. ″There are opportunities to get paid for it, specifically through Medicare,″ Traylor explained. ″And Medicare sets the tone for insurance coding, so a lot of private insurance companies follow suit.″
Beyond Medicare reimbursement, the individual contracts with hospitals and other providers can prove lucrative. ″Hospitals are highly motivated to get their overall scores up,″ Traylor said, which means they will pay out in their contracts with pharmacies.
When L & S first started providing transitions of care services, they entered into a pilot program with their local hospital. It was no cost to the hospital at the beginning, but they’ve moved on to a fee-for-service model where they bill providers each time they perform a service that is covered under their contracts.
At Lily’s Pharmacy, most of their transitions of care patients are enrolled in the pharmacy’s medication packaging program, which nets a tidy $30 per patient per month. The main benefit of transitions of care hasn’t come from prescription revenue, but the individual contracts with providers.
″We’ve seen a 300 percent return on investment with our transitions of care program,″ Shannon said, mostly attributed to the program’s slow but steady expansion into more facilities throughout the area. ″It started on two floors of the hospital, then it went into the whole hospital. Then it expanded out to the rehab facility and to smaller practices in the area. And now we’re doing transitions of care for basically all the fire departments and EMS in our area.″
Though getting a foot in the door was a challenge, Lily’s transitions of care program has proved its value to providers, which allowed it to grow into a profitable powerhouse.
Establishing a provider relationship
One of the most difficult challenges of providing transitions of care services is breaking into the market—making those first connections with hospitals in your area and convincing them your services will actually save them money.
When Lily’s Pharmacy first opened, Shannon’s primary goal was to provide transition services that would help reduce readmission rates, but establishing that first relationship took a lot of legwork.
″Nobody knew who we were. I was literally calling the hospital every week saying, ‘Hi, I run Lily’s Pharmacy and I would love to collaborate with you. Call me back.’ And nobody would call me back.″
After finally getting a real person on the line, Shannon made her case to the hospital’s director of pharmacy about how a transitions of care partnership had the potential to improve patient outcomes and save the hospital money. They were sold. The hospital even canceled a meds-to-beds program they’d had with a large chain pharmacy in favor of Shannon’s proposal.
From that meeting, it took some time to get things up and running. They had to wait on the lawyers to get the legal language just right and also become a preferred provider.
“We’ve seen a 300 percent return on investment with our transitions of care program.”
Richard Logan persuaded hospitals by using data about readmissions that most of the hospitals were completely unaware of. ″The majority of hospital readmissions and the penalties they were suffering were because of medication mismanagement,″ said Richard Logan. ″So we took that information to the hospital.″
In a brief meeting with local healthcare entities, he presented a PowerPoint highlighting readmission stats and his proposed solutions. ″At the end of the little five-minute presentation, there was silence. I thought, ‘Did someone bring a skunk into the room?’ But then they were saying, ‘Why haven’t we been doing this all along?’″
One key to their argument was reminding hospitals that there was more to pharmacy services than someone counting pills behind the counter. The pharmacy could share the burden with the hospital so they could work less, get paid more, and have healthier patients.
Although the Logans presented solutions to the hospitals, more importantly they listened. ″We asked the questions, ‘What do you need from us? What are you struggling with and what could be helpful?’″ Tripp Logan said. ″We didn’t go in and tell them what we were going to do for them. We went in and asked what we could do.″
To make these crucial connections, pharmacists will have to step away from the counter. You may cringe thinking about the lost work time, but Tripp Logan encourages pharmacists to think of this time away from the counter in terms of marketing. ″For a pharmacist to step out for an hour-long meeting, that’s $65 or $100,″ he said. ″If you consider that against Facebook ads, television, or whatever marketing opportunities pharmacies use, that time spent away is similar to a typical marketing budget.″
Getting out in your community will help you attract patients who need complex care, which is worth more in the long run than winning over patients with one or two low-cost prescriptions. ″It’s a pivot we’ve had to make in the last 10 years to attract the right partners and the right patients, just in a different way than your typical marketing efforts,″ said Tripp Logan.
Traylor recommends not limiting your search for a partner to hospitals but to include local healthcare practices and nursing homes, too. The bigger the organization you partner with, the more it will disrupt your workflow. If you aren’t ready for a large influx of prescriptions and counseling sessions, starting with a smaller provider may be a wise choice
Connecting with patients
Beyond the contracts with providers, a transitions of care program can introduce you to new patients—and win them over for the long term. The care that patients get when they transition from hospital to home can lead to a light bulb moment when they realize the depth and breadth of services independent pharmacies provide. ″It’s not an auto-fill program. You’re reviewing patients’ medications each month and preventing problems before they interfere with the patient’s life or care plan. And you’re helping them live a healthier life with minimal medications,″ said Traylor. ″That absolutely helps win over new patients.″
Because Lily’s Pharmacy started working in transitions of care right when they opened their doors, they didn’t have a large base of existing patients on the retail side. Shannon estimates that the majority of their current patients initially connected to the pharmacy because of their transitions of care services.
Typically, transitions of care patients will switch over their existing prescriptions to Lily’s after going through the transition program. ″For the most part, they become long-term patients,″ Shannon said. ″They realize it’s not just the transition of care, but the level of care they get all the time.″
Although L & S Pharmacy does connect with new patients through referrals for their transitions of care services, the sweet spot is getting more from their current patients. They already use the pharmacy to fill their prescriptions but then become eligible for transitions of care services after a hospital stay or are recommended for chronic care management by their physician.
″That’s the easiest one to organize because the relationships are already there,″ said Tripp Logan. ″And that’s essentially what partners are paying us to do—to support the patients that already frequent our pharmacies with the things they need help with.″
Transitions of Care for Self-Insured Companies
Most pharmacies that provide transitions of care services will turn to a hospital or private practice for a partnership. But that’s not the only way to make an impact.
Sarah Oprinovich is the program manager for a series of pharmacies located inside Balls Food stores, a grocery chain in the Kansas City metro area. The stores are self-insured, and transitions of care services are provided to employees by the pharmacy to keep the company’s healthcare costs down.
″We get notification from insurance or our third-party administrator that one of our employees has been in the hospital and we get their diagnosis,″ Oprinovich explained. ″Then the pharmacist will reach out and do medication reconciliation and counseling.″
The program is open to almost every kind of hospital discharge, from motorcycle accidents to diverticulitis. The only conditions they don’t tackle through transitions of care are substance use disorder and patients entering long-term care.
For most patients, the intervention ends after they receive their medication reconciliation and counseling, but patients with conditions like diabetes or cardiovascular problems will be enrolled in the pharmacy’s disease-state management program for more thorough follow-up.
Like a traditional transitions of care program, the intent is ultimately to reduce hospital readmissions, but it’s the self-insured employer that reaps the benefit of the associated cost savings rather than the hospital.
Since they don’t base services on contracts with individual hospitals, the pharmacy can give transitions of care services to any patient, regardless of their hospital. However, Oprinovich has faced some challenges with waiting on insurance to get the pharmacy the information they need to initiate services.
″There’s often a delay,″ she explained. ″Normally you’d want to provide discharge counseling within the first couple of days after discharge, but sometimes we wouldn’t even get notified for over a week, depending on how long it took the hospital to send the bill and how long it takes for a report to be generated and so on.″
However, once they actually receive notification, Oprinovich says that working with local health systems to coordinate care has been relatively simple, even without a formal transitions of care agreement in place.
For companies that are self-insured and shouldering high costs when their employees are hospitalized, the idea of reducing readmissions can be very appealing. And for pharmacies that may not be ready to commit to taking on the prescription and counseling volume that comes with working with a hospital, proposing transition services to businesses in the area could be a way to break into transitions of care with minimal disruption to existing workflow.
When you introduce transitions of care services, expect slow but steady changes to your pharmacy workflow. Before you even start offering the service, Traylor recommends shifting from a ″reactive″ to a ″proactive″ workflow to help you prepare for increased volume. ″That means the pharmacy isn’t just waiting for a patient to come in and refill their medications,″ she explained. ″They are using clinical med sync to make sure patients have all their refills lined up.″
After a pharmacy has a significant portion of prescriptions being filled proactively through medication synchronization—around 40 to 50 percent, Traylor recommends—adding transitions of care services will be seamless, because the system is already in place.
″Once you hit critical mass with your med sync programming, you’ll be able to retool people’s positions,″ said Traylor. ″I would definitely say you need a strong technician who has good rapport with patients.″
At Lily’s Pharmacy, transitions of care services are a team effort. As a top priority, every technician and pharmacist is trained to do their part. ″I like everyone to know how to do everything in our pharmacy. The whole team gets involved,″ Shannon said. ″We can constantly remind each other, ‘This person is leaving tomorrow, do they have everything they need?’″
To keep everyone on the same page, there’s a constant cycle of adaptation and communication. ″Especially during Covid, we frequently met so the whole team knew what was going on,″ Shannon said.
L & S Pharmacy has seen a gradual growth of their pharmacy team since introducing transitions of care and chronic care management services over the past decade.
″Our team has evolved, but it’s evolved based on funding,″ Tripp Logan said. ″We’ve been able to bring on people to support these initiatives, but it was never unmanageable because we weren’t overwhelmed with a thousand new patients all at one time. It’s a slow relationship.″
Over the years, people have been hired to meet the needs of the growing program while others have had their roles and duties shifted, but none of these changes happened on day one of the program.
Over the years, Lily’s Pharmacy and L & S Pharmacy have adjusted their programs so things run more smoothly.
One thing Shannon says she would do differently is forego home visits. ″I was so eager to get the full picture, but every time you go into a house, you don’t know what you’re going to walk into.″ Not to mention, the home visits demanded a lot of time away from the pharmacy. Keeping the service inside the pharmacy means the staff can focus on care in a neutral environment, plus they have the benefit of the rest of the pharmacy team being there to help if needed.
L & S was sure their services could make a difference in their community, but Tripp Logan says their mistake was thinking they had all the answers. ″We assumed we had the answer only to find out there were 500 different possible answers and we only had one of them.″
He advises pharmacies to look around at other independent pharmacies and learn from their mistakes instead of making the mistakes firsthand. He said, ″We’re very involved with CPESN right now, which means we don’t have to reinvent the wheel every time.
A lot of times colleagues have learned those lessons for us, and in turn we’ve tried to share what we’ve learned and best practices with others so it’s not as expensive for them to start these programs.″
By getting outside of the bubble of your own pharmacy and talking to the in-patient facilities in your area, you can design a better program. ″You have to look at total care and what it means for your community. That’s part and parcel of what we’re doing,″ said Richard Logan. ″It’s community care.″
From the Magazine
This article was published in our quarterly print magazine, which covers relevant topics in greater depth featuring leading experts in the industry. Subscribe to receive the quarterly print issue in your mailbox. All registered independent pharmacies in the U.S. are eligible to receive a free subscription.
More articles from the September 2021 issue:
- Is transitions of care a good business opportunity for pharmacy?
- These are the top trends in secondary purchasing
- New guidelines define pharmacist responsibilities and rights
- Millions are incarcerated–and they need meds
- An attorney’s guide to succession planning
- Pet medicine is making this pharmacy profitable
- An inside look at the opportunity of long-acting antipsychotic medications
- Essential merchandising tactics to increase retail sales
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