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More and more I speak to pharmacists who have identified opportunities to provide a readmission reduction programs (Note. As re-admissions are a a result of a care transitions they are also referred to as transitions of care programs.  We will refer to them synonymously in this article.).  Readmission reduction is a compelling reason for operating and paying for a medication management program.  Medicare spends approximately $26 billion a year on patients who were re-admitted  within 30 days of a discharge.  In addition, the biggest reasons for early readmissions are medication related.  So a medication focused care management program could significantly impact early readmissions and is well within the “wheel well” of a pharmacist.

Currently, Medicare imposes a 3% penalty and extracts approximately $425 million in fines from hospitals.  This amounts only $250 per re-admission.  A decrease in revenue that, up until now, has not been particularly interesting to hospitals.  However, this could be changing.  Medicare (and soon other payers) will move to reimburse hospitals on a “bundled payment” basis.  For example, a hospital will be paid a fixed amount for a knee surgery, with the cost of all admission and re-admissions being covered by the same bundled payment.  Readmissions will no longer generate any additional revenue and be pure money losers for the hospital.  In addition, hospitals are also subject to Medicare quality ratings – STAR ratings – with 2 of the ratings being communication about medication and discharge information.

Traditionally, hospitals have had a difficult time engaging the nationally acclaimed transitions programs as their price tag’s exceed the $250 per admission penalty they were designed to avoid (Note.  Guided Care program ~$1700 per patient per year, Geriatric Resources for Assessment and Care of Elders (GRACE) program ~ $1,432, Transition Care Model8 (Naylor Model) ~ $982.)   The most popular care transitions program – Care Transitions Intervention (Coleman Model) – has been reported to cost ~$196, however, a number of transitions care providers have had difficulty producing Coleman Model programs at this price point.

Upshot is that that the time is right for a pharmacist driven, medication focused readmission reduction program.


While your transitions programs needs to be priced at a “market” price point, it must include some key features

  • The Hand Off.  How will hospital staff identify and notify you of patients who are getting ready to be discharged and eligible for the program.  Most hospitals produce an ADT (Admissions, Discharge, Transfer) file.  This file is produced at least daily and indicates who is ready to be discharged.  In my experience, it is always better if your program doesn’t produce extra work for your client.  To minimize extra work for your client your program might include becoming a business associate of the hospital with access to this file. Your staff monitors the program and recommends patients for inclusion.
  • The Criteria.  What are the criteria that will make patients eligible for your program?  Suggest certain age range, disease states, types or number of medications and let your client choose what might be best for them.
  • The Process.  What is your transition care process?  Here you need to be specific.  You need to describe how and when you will contact the patient and what you will be doing at each patient interaction.  You especially, need to have this well mapped out if your program is new and has no “track record”.  In this case, the process will be your primary resource for convincing hospital administration that you can actually prevent readmissions.  You don’t need to re-invent the wheel, use the processes that have been developed by other successful programs.  Components that are critical to a care transitions program might include:
    • Medication Reconciliation.  Understanding the discharge medications, previous medications and coming up with a consensus list for the patient, primary, pharmacy and specialists.
    • Primary Care Visit.  One of the key features of transitions programs that reduce re-admissions is a primary care visit within a week of discharge.
    • Medication Synchronization and Compliance Packaging.  Getting the patient’s medication in a form that the patient can easily adhere to their regimen in a consistent and reliable manner.
    • Documentation and Reporting.  You will need to have a system for documentation and reporting.  In essence you will need your own electronic health record, that allows you to document that you completed all the aspects of your care process and that it resulted in reduced re-admissions for patients.


I am a big fan of the minimally viable product – deliver a product that provides only the essential components required to produce the promised result.  At some point you may want to consider adding additional services to your program offering.  These can be a part of the core program or add-ons that a client could elect.  Some examples of additional services are:

  • Transportation coordination.  Many patients will be re-admitted because they have no body to take them to their medical, physical therapy, etc. visits.
  • Meals.  Poor nutrition has been sited as a key factor in increasing early readmissions.  Coordinating with meals-on-wheels and other nutritional services may be a low capital add on service.
  • Home Safety Inspection.  Falls are also a large factor in early readmission.  Home safety inspections identify loose carpets, bath safety issues, etc. which might promulgate a fall.  While a home safety inspection is generally conducted by an Occupational Therapist and outside the scope of medication management services it is a service that can be coordinated by the medication management pharmacist.


Developing the most effective care transitions program around, is not an assurance of success in the market place.  You have to communicate the value of your program to potential clients.

  • Be persistent.  Use your network to find the key decision makers.  The Director of Pharmacy or Discharge Planners will likely be key decision influencers, but maybe not the decision makes.  Likely you will need to speak to somebody who is responsible for hospital quality and managed care contracting.
  • Who are you?  Be prepared to provide a short synopsis regarding who you are.  Make sure to highlight the fact that you are part of the community and not “fly-by-night”
  • Evidence.  Provide success stories.  If your program is new and has no track record, but you have modeled your program after other successful programs  you can “tag-on” to their successes.
  • Understand Your Potential Client.
    • You should look up hospital readmission rates in your area and the penalties that they have paid.
    • Understand how your client is reimbursed and the coming reimbursement challenges.  Read up on bundled payments.  Being able to discuss these topics fluently will convince your potential client that you have an understanding of the challenges they are facing
  • Risk.  You will likely be asked if you are willing to “take risk” on your fee’s.  This means that your fee’s will be based, either in whole or in part, on your ability to prevent readmissions and meet other performance goals.  You should have thought through what a risk agreement might look like and understand your tolerance for risk.
  • Don’t Be Afraid of No.  To get a “Yes” you will have to listen to a lot of “No’s”.  No’s are actually sales “gifts” as they provide feed back for evolving your offering, and No’s provide the opportunity to get permission to loop back and assess the future client’s needs in the future.  You have to be “top of mind” when your client is ready to engage you.
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