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Transitional Care Pivots Toward Improved Performance

By ASD Healthcare

Emerging models adjust risk to the patient population, pull through the appropriate patients and quantitatively measure results.

Hospitals and health systems have clear financial incentives to reduce readmissions within 30 days of discharge. For several years, CMS has penalized hospitals with higher-than-expected readmissions up to three percent of their base payments on all Medicare inpatient reimbursement.  Additionally, Medicare does not reimburse hospitals for the DRG associated with the readmission. In fiscal year 2016, hospitals incurring the maximum penalty saw their base Medicare reimbursements reduced by an average of $305,000.1

At the same time, hospitals recognize that medication management and proper adherence are closely associated with the incidence of readmissions. Studies dating back more than a decade show that more than 40 percent of medication errors stem from inadequate reconciliation in handoffs during admission, transfer and discharge of patients2 — and about 20 percent of such errors result in patient harm.3

From a broad view, payers like Medicare are shifting the paradigm from fee-for-service to risk-based models that will have a practical impact on the overall health and wellness of patients. In response, hospitals and pharmacies must find ways to better manage patients. And not just for 30 days; now, for instance, for a 90-day episode of care with shared responsibility among entities along the transition-of-care pathway.

Technology’s Role in Advancing Transitions

The healthcare industry and, more specifically, pharmacy, is seeing emerging solutions to support a hospital’s efforts through medication management to reduce costly readmissions, improve ambulatory pharmacy financial performance and support patient-centric medication adherence goals.

Within the value-based framework, once a patient is discharged from an inpatient encounter, medication adherence is vital because the hospital can still be at risk for a readmission or, in some cases, another costly episode such as an emergency department (ED) visit. As providers and pharmacy stakeholders seek to gain greater control over patient management and outcomes, they’re leveraging intuitive, actionable analytics and technologies to track key elements of a patient’s episode of care. This enables health systems to establish pre-determined interventions to drive compliance and adherence.

At the forefront, hospitals are using data analytics to perform upfront stratification of patients, identifying those who are at high risk for readmission. Additionally, a pharmacy-specific element examines community-based prescription fills to identify gaps or duplications. This pharmacy-centered approach adds specificity and accuracy to the initial risk score so care teams can allocate resources and support to those patients who represent the greatest exposure for readmission risk.

In tactical terms, analytics can help drive a readmission-reducing, pharmacy gross-margin-improving “meds-to-beds” program in which the pharmacy facilitates medications and counseling to the patient’s bedside prior to discharge. In one meds-to-beds study, only five percent of patients who received medications via bedside delivery (and who also received a follow-up phone call 2-3 days after discharge) were readmitted. In contrast, readmissions occurred among 9.5 percent of patients who received usual care at a hospital without a transitional care program.4

It’s a matter of pursuing the right patients — those who make up the hospital’s largest risk for readmission — so they can be enrolled in a pharmacy-supported transitional care program, receive their medications at discharge, have their medications explained to them and confirm they can afford their prescriptions.

A recent pilot program conducted at the University of Tennessee used a pharmacy-supported, transitions-of-care program that tracked patients who “opted in” or participated in the pharmacy discharge program and compared them to a non-participating, “opt-out” control group. Through real-time analytics, researchers could determine whether non-participating patients filled their discharge prescriptions in the community and if, as a result, they were readmitted. The findings showed, on a risk-adjusted basis, a greater than 20 percent readmission reduction between patients who opted in to the pharmacy program versus those patients who opted out. 

Through leveraging the analytics, pharmacy can risk adjust the patient populations, which removes factors other than medications that ultimately attributed to mitigating the readmission. The resulting assessment isolates the extent to which the pharmacy intervention positively affects the patient’s outcome. As a result, pharmacy can quantitatively demonstrate to administration that pharmacy-supported transitional care programs have a substantial, statistically significant effect on mitigating readmissions.

A Fit for Population Health

In many cases today, hospitals proactively raise awareness about their respective pillars of excellence. In effect, they’re selecting the “right” patients to flow through the health system, enrolling those patients in disease state-specific programs or clinics at the earliest possible stage.

Further downstream, expect hospitals to blend transitional care programs with other technology-based initiatives to improve patients’ overall experience once in the system. For example, EHR extensions such as smartphone apps can give patients direct access to an adherence program that sends text messages and reminders to take their medications and keep their follow-up appointments. This type of consumer-driven approach not only boosts patient engagement but also drives healthier behaviors.

Without a doubt, these types of activities and technologies have become more broadly accepted and mainstream. It’s an exciting time, sparked by opportunity. Health systems, and more specifically pharmacy leaders, that adopt these forms of technologies and analytics will be best positioned for the future.

To learn more about powering transitional care with analytics and the case study mentioned here, read the Pharmacy Healthcare Solutions white paper.


1. Besler Consulting. Overview of CMS readmissions penalties for 2016. 8 September 2016. Accessed 23 March 2017. Available online at
2. Rozich JD et al. Patient safety standardization as a mechanism to improve safety in health care. January 2004. Accessed 23 March 2017. Available online at
3. Gleason KM et al. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. August 2004. Accessed 23 March 2017. Available online at 
4. Kirham HS et al. The effect of a collaborative pharmacist-hospital transition program on the likelihood of 30-day readmission. 1 May 2014. Accessed 23 March 2017. Available online at

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