Partnering with physicians, medication reconciliation reduces readmission in HF patients

WASHINGTON — Partnering with community physicians, having nurses take responsibility for medication reconciliation and arranging follow-up appointments before discharge are among the strategies that can significantly reduce readmission rates, according to data presented at the American College of Physicians Internal Medicine Meeting.

Ileana L. Piña, MD, MPH, of Montefiore Medical Center Einstein Campus, in the Bronx, New York, described how she and her colleagues tested what they called a “Brown Bad Clinic,” in which officials combined increased patient education, follow-up meetings and a team-based approached among physicians and nurses in an attempt to cut down readmission rates among patients with heart failure.

Ileana L. Piña, MD, MPH

“It all really depends on your system of care,” Piña said. “If you don’t have a way to respond to abnormal signals, why are you getting them, and if you can’t empower the people who work with you — your team — to make changes, why are you spending all this time and money? So, for years, we functioned frequent visits, with our nurses getting on the phone with the patients, and I can’t do this alone, I need a team, and we work with a team to get the patients well.”

According to Piña, strategies included clinic sessions staffed by clinical hospital pharmacists, who acted as “preceptors,” with a nurse practitioner, fellow and/or attending physician also available.

This, Piña said, helps to eliminate the “poly-pharmacy” effect, in which patients take more medication than is necessary, or maintain several duplicate medications.

“The patients get a letter that says put all of your medicine, what you have under the sink, in the shoebox, or next to the coffee pot, the pill bottles that they have everywhere in the house and the ones they’re still using from three years ago, and put it all in a bag and bring it in,” Piña said. “And we find that patients leave the hospital with about 13 drugs; you tell me how you take 13 drugs in a day. That’s all you would do all day. So we get rid of the junk that they leave the hospital with, and they leave the hospital with a lot of junk — the stool softener, the laxative, the sleeping pill. I get rid of them. I want them to take the drugs that they need to keep their heart as well as possible and keep them out of the hospital.”

Patient and caregiver education included counseling on the indications and adverse effects of medications, a booklet entitled “Living with Heart Failure,” an updated medication list in EMR, a letter sent to the cardiologist regarding changes made, or updates, to the medication list during the clinic, and making a point of scheduling a follow-up appointment.

Additional strategies included having a process in place to send all discharge papers or electronic summaries directly to the patient’s primary physician and assigning staff to follow up on test results after the patient is discharged.

According to Piña, the 30-day readmission rate in the control group was 27%, out of a total of 103 patients, with 18% readmitted due to heart failure. In comparison, just 1 patient out of 73 enrolled in the Brown Bag Clinic, or 1%, had been readmitted within 30 days. That patient had initially been admitted for heart failure.

The 90-day readmission rate among patients in the Brown Bag Clinic was 11%, or 8 out of 73, compared with 52%, or 54 out of 103, among patients in the control group.

“The more strategies you have, the more places you can target this problem, the better you will do with the readmission rate,” Piña said. “It’s really raising the bar. I brought these guidelines to Montefiore because I wanted everyone thinking, ‘heart failure.’ If they would think ‘heart failure,’ they would think of what are the things we need to do for these patients, and make them better.” – by Jason Laday

Disclosure: Piña reports no relevant financial disclosures.