Article by Mel Green, GrandView Pharmacy, Director of Business Development- South Region

Hospital readmissions for the elderly living in a senior care community could lead to potential negative physical, emotional, and psychological effects. Hospital readmissions are also extremely costly for the Medicare program, which contributes to billions of dollars in additional healthcare cost.

If all healthcare providers serving our senior population in senior care communities work together as a team we can greatly reduce readmissions whenever possible.  In a world with greater communication tools there is really no reason providers cannot work together to benefit the community’s nursing staff and residents to reduce rehospitalization. The action of hospital readmission has been identified by policymakers and providers as an opportunity to reduce overall health care system costs through improvements in quality. The issue has become a top priority for the Centers for Medicare & Medicaid Services (CMS) and managed care programs. One of the ways policy makers are attempting to reduce rehospitalization and improve quality of care in Skilled Nursing Facilities (SNF) is through the Value Based Purchasing (VBP) Program, a CMS effort that links financial outcomes to quality performance that began on October 1, 2018.

It is important for senior care providers to work with all of their healthcare vendors to help stay in compliance with the CMS requirements of participation. As vendors who directly or indirectly effect patient care, we are obligated to assist you with providing quality health care to your residents, and also assist with making your care processes better in order to produce positive patient outcomes.

In this article I would like to focus on how your long term care pharmacy provider can help assist you with reducing the potential of hospital readmissions. The first step is simply getting the right medications to your residents in a timely and accurate manner. Through Lean Six Sigma, a methodology that relies on a collaborative team effort to improve performance by systematically removing waste and reducing variation. (THIS SENTENCE ISN’T FINISHED) The Lean Six process combines lean manufacturing/lean enterprise and Six Sigma to eliminate the eight kinds of waste (muda):

  • Defects
  • Over-Production
  • Waiting
  • Non-Utilized Talent
  • Transportation
  • Inventory
  • Motion
  • Extra-Processing

Our executives, who have been trained in Lean Six Sigma, reviewed our fulfillment process for medications to senior care communities and identified 6 barriers that could negatively impact the timely and accurate deliver of medications. Therefore, we have since developed programs to reduce the occurrence of these barriers. A missed medication or in accurate medication could contribute to an adverse effect for a resident and possibly lead to a rehospitalization. So, it is imperative that your long-term care pharmacy provider has programs in place that allows them to delivery every medication order timely and accurately with the greatest efficiency.

Here are the 6 barriers to the accurate and timely delivery of medications my Lean Six Sigma Team identified:

  1. Controlled Substances- The pharmacy needs a valid prescription from the physician before they are legally allowed to fill and delivery the medication. There are many factors that may cause a delay in getting the required prescription from the physician to the pharmacy. The physician may not be available, there could be communication issues (i.e. a faulty fax communication), or the pharmacy receives a controlled prescription that may not be legible.
  2. Order Clarification- Order clarifications are needed when the pharmacy notices that an order may not be matching what is currently or previously prescribed for a patient. Order clarifications are also needed if an order or prescription is not legible when received at the pharmacy. Therefore, this could cause a delay in the fulfillment of the medication or inaccuracies in the filling of the medication.
  3. Product Availability- There are times when a pharmacy may not have a medication in stock or there may be an issue of getting the medication from the wholesaler or manufacturer. This causes a delay in the delivery of medications from the pharmacy.
  4. Insurance Coverage, Refill Too Soon- Most insurance providers manage the filling of medications. If a pharmacy attempts to submit claims to an insurance company for a medication that was recently filled for a patient, the pharmacy will receive a denied insurance claim saying it is too early to fill this medication. This often occurs for senior care residents when they have had a prescription filled at retail pharmacy prior to moving into a senior care community. They may have a supply of medications at their home, however, the nursing staff submitted another order to the long-term care pharmacy for supply while the patient was at the facility. This type of scenario may also produce a denied insurance claim due to the medication being filled too soon.
  5. Insurance Coverage, Non-Covered Items- Most insurance companies have a formulary (a list of covered medications for the insureds policy). Unfortunately, insurance providers change their formularies from time-to-time, and a medication that was once covered under a policy may no longer be covered and now the patient is required to pay out-of-pocket. When an insurance claim is denied for lack of coverage then the pharmacy will delay filling the order until a payor source is identified.
  6. Human Error- Lastly, human error can delay the timely and accurate delivery of medications. Human error can occur on the care provider side, the pharmacy side or even with the insurance provider. A forgotten fax, an inaccurate entry of a medication, or a wrongly denied claim are just some examples of human error that can lead to medications not being delivered timely and accurate.

Overall, it is important to work with your pharmacy provider to implement systems that produce consistent, accurate and timely delivery of your resident’s medication. The accurate and timely fulfillment of medications for your residents is the foundation for any pharmacy provider. This can help your nursing staff provide quality care to your residents and help reduce the potential of rehospitalization.

In the months ahead we will review other systems and programs you can implement to help reduce rehospitalizations.