As a follow-up to the UNC catalyst events, we would like to keep the conversation going by highlighting participant examples of collaborative pharmacy practice models. As such, we will be disseminating a series of case studies over the next few months with the goal of exchanging innovative ideas and best practices. We encourage you to reach out to the case study authors to learn more. Our fourth case study is IndyCare TCM Collaborative Model by Greg Vassie (email@example.com).
- 1 in 5 Medicare beneficiaries discharged from hospital receives post-acute care in a skilled nursing facility (SNF) at a cost of $28B annually.
- Nearly 1/4 are readmitted to hospital within 30 days after SNF discharge.
- SNFs are now accountable for readmissions and subject to 2% penalty or bonus on all FFS payments from CMS
- IndyCare partners with local pharmacies to provide a TCM service for discharged patients to lower readmission rates and increase the facility’s quality scores. The local pharmacist contacts patient after discharge, performs a medication reconciliation, deliver prescriptions and schedules TCM consult with an IndyCare medical provider.
- The medical provider reviews discharge instructions, educates patient & caregiver on their care plan, ensures other prescribed resources are in place (e.g. home health, PT, labs, etc.) and that they have a PCP f/u appointment scheduled. They review signs & symptoms of their medical condition worsening and provides steps to mitigate an exacerbation other than returning to the hospital emergency room (if can be safely managed at home with pharmacy bringing meds if needed).
- The full medication reconciliation and consult note from the pharmacist and IndyCare provider are then sent to the patient’s PCP to ensure a ‘warm handoff’ as the PCP re-assumes the patients care after the SNF stay.
Drivers of Success:
- Pharmacists are experts in medication reconciliation and there are many medication changes between hospital, SNF and community.
- Pharmacies deliver into the patient home and have insight on other needs the patient may have in their home to support a successful transition after discharge.
- IndyCare providers address a critical time gap between the SNF discharge and PCP follow-up which on average is 21 days, where the patient needs education and support with their care coordination.
- SNF facilities love the program and see pharmacists as an important community partner. They understand the impact on patient outcomes and their facility STAR ratings. However, the referral process is very manual and staffing and training challenges lead to an inconsistent pattern of referrals to the pharmacy partners.
- PCPs appreciate the ancillary support for their patients and the clear communication from IndyCare. They realize it is difficult to quickly reach these patients after discharge and get them on their schedule and the potential risks during that waiting period. However, most PCPs work in health systems that deploy their own TCM solutions such as Nurse call centers and discourage external referrals. This limits the opportunity for the program to support additional at-risk patient discharges such as post-acute hospital stays.
- This program has been implemented with 3 community pharmacy partners. None of the patients receiving the collaborative TCM service has experienced a 30-day readmission. However, patient discharge referral volume has been low due to the challenges with the manual referral process limiting the overall impact of the program.
- IndyCare recently partnered with a technology firm that can provide automated SNF discharge notifications and med lists for the pharmacy’s patients.
- IndyCare will leverage this revised, technology-driven solution to scale up the SNF TCM program with independent community pharmacy partners across the state.