Under the Affordable Care Act (ACA) and its Hospital Readmission Reduction Program (HRRP), excess hospital readmissions requires the Center for Medicare and Medicaid Services (CMS) to reduce reimbursement. Hospitals began to establish and implement transitions-of-care services through their acute care and outpatient clinics by collaborating with pharmacy services.
It is estimated that 20% of patients experience adverse events (AEs) in the first two weeks after hospital discharge, of which over one-half are preventable. Seniors, by virtue of their multiple medication regimens and co-morbidities, tend to be at higher risk.
Programs in several states have targeted post-hospitalization residents of skilled-nursing facility (SNF). Since under HRRP, hospitals stand to lose portion of their reimbursement, task forces at these institutions focused on efforts to improve the transitions of care and reduce preventable readmissions. Pharmacist as part of the interdisciplinary team were very instrumental in the process especially in medication reconciliation, communication with SNF staff and patient education when appropriate. However, some of the external challenges the hospital's transition-of-care services faced were the ability to effectively reach and monitor patients once back in the SNF. These challenges could very well be alleviated by the presence and identification of a transition team at the SNF who can engage the facility staff. Consultant pharmacist, by virtue of their training, and capacity to navigate the SNF chain of command are at a great advantage of becoming the point of contact in bridging the two institutions and ensuring a safe and effective transition.
