Local nurses find medication management can keep patients out of the hospital

With an average of 15 prescriptions to manage, Concord Regional Visiting Nurse Association patients needed help. There were expired prescriptions, unanticipated interactions, wrong doses and patients who shopped around for the best deal, leaving them with no pharmacist who could see the big picture of all the drugs they were taking – the visiting nurses saw it all.

Research by the association showed misuse or misunderstanding of medication was one of the primary reasons almost 1 in 3 patients in the Concord area were being readmitted to the hospital within five days of discharge a few years ago.

Rehospitalization is risky and disruptive for patients, and it’s costly for the nation’s health care system. Readmissions cost Medicare $17.5 billion on inpatient care in 2010, according to the Centers for Medicare and Medicaid Services.

Another report released in February by the Robert Wood Johnson Foundation showed 1 in 8 Medicare patients were readmitted to the hospital within 30 days of being released after surgery in 2010, while 1 in 6 patients returned to the hospital within a month of leaving the hospital after receiving medical care.

Facing a readmission rate higher than average – 27 percent within five days of discharge in 2009 – the visiting nurse association began researching ways to help patients better manage their medications and to avoid return trips to the hospital.

That research led to a New Hampshire Charitable Foundation grant in 2012 for a pharmacist to spend four hours per week reviewing patient medications with the nursing staff. The readmission rate for the especially vulnerable patients lowered to 24 percent in one year.

This year, the association hired that pharmacist, Lori Connors, for two full days each week. She first worked

with nurses on about eight patients each week, but last Monday, she reviewed 22 patient files. (The association has employed a pharmacy consultant for its hospice program for nearly 15 years as a budgeted position, said Director of Communications Andrew Morse.)

The association’s 60 nurses work with about 900 patients in some way each day, though for some patients, that means only that their vital signs are checked via a tele-health system linked to their self-testing, such as the blood tests done by a diabetic patient.

Connors worked with the patients most at risk of rehospitalization – patients with chronic illnesses or multiple, complicated diagnoses. She reviewed the files with the nurses, taking about five minutes to go through the patient file.

“We often identified either this patient’s on too many meds they don’t need, or this dose doesn’t match this diagnosis, or this drug doesn’t match.

Then I would go back to the computer after the meeting and read through the notes from the nurse visits.

I could really match up each diagnosis with each prescription, and what’s left over and why, or see that they could benefit from something they aren’t on,” Connors said.

“A lot of these patients have a med list at home. Then they go to the hospital and get a med list there, and they’re working off both. My position is very advantageous, because even though there’s a pharmacist in the hospital who knows what they are doing on discharge, and there’s a pharmacist at CVS who only sees the prescription you’re bringing in, we have the best of both worlds because we have the nurse in the home who can sit with the patient and actually see the bottles they are taking.”

Sometimes, patients don’t notice that they have two prescriptions for the same drug, one under a brand name and one under a generic name, and they take twice the necessary dose.

Other times, to save money, they take expired medication once prescribed to a spouse who no longer requires the drug, she said.

When she’s not at the association, Connors works as a pharmacist at The Prescription Center on North Main Street. She knows where prescriptions can be obtained on a discount program – which manufacturers offer discount programs or coupons or prescription payment assistance – and she can help patients get on the right dose of the right medication.

“It’s really about moving from the idea of the patient being noncompliant and moving to ‘how do we tailor this for them?’ ” said Denise Martel, the association’s clinical education and development coordinator.

Surveys given to the patients Connors worked with last year showed an increased satisfaction with their medication management (from 81 percent to 87 percent) and an improved ability to correctly take their oral medications (from 38 percent to 51 percent).

Connors and Martel spoke about the program during a national webinar June 17 for the American Hospital Association’s Health Research and Educational Trust Hospital Engagement Network.

They said other networks were really interested in the work they’ve done – “They asked for a copy of our grant proposal,” Martel said, laughing – but the networks aren’t completely willing or ready to add a pharmacist to their own staff.

Other organizations have been slower to adopt in-house pharmacological experts because Medicare won’t reimburse them for that expense, said association President and CEO Mary DeVeau. But as the Medicare landscape changes in the direction of bundled payments, visiting nurses and medication management might become part of standard patient care, especially for people recently discharged from the hospital and at risk of readmission, she added.

“As part of the continuum of care, it’s in the best interest of our patients for us to make the investments we’ve made, the pharmacist, the nurse, the education,” DeVeau said. “Part of our community responsibility is to make those investments for the patients we serve . . . so that when the payment streams change, we’ll be able to negotiate payments for not only the cost, but something that allows us to continue everything we’re doing.

“It’s the proactive approach to the transitions that are happening in health care instead of the wait-and-see approach. You can always wait and see, but does that build up an agency’s capacity?”

The association is offering a free presentation on self-management of medication for the public from 10 to 11 a.m. Thursday, July 25, at Concord Recreation Senior Program, 14 Canterbury Road in Concord. For more information, call 224-4093 or 800-924-8620, ext. 5815.

-Sarah Palermo at The Concord Monitor