1. O'connor, Mary Ann RN, BSN, MBA
  2. Pike, Adele EDD, RN
  3. Ambrefe, Mary Meade PHARMD, CGP
  4. Greenberg, E. Liza MPH, RN

Article Content

We know from experience that the typical home care patient is at high risk for hospital readmission. Compared to Medicare beneficiaries not served by home healthcare, home healthcare patients are older, more likely to live alone, have three or more chronic conditions, and have two or more limitations in activities of daily living (Alliance for Home Health Quality and Innovation, 2014). These patients also tend to take a lot of medications (Runganga et al., 2014). Medication teaching and medication reconciliation are two high-priority objectives for home care clinicians. Although the causes of medication errors are multifactorial, some home care clinicians believe a more proactive approach would help ensure safe medication use by homebound seniors.


Several studies have examined the relationship between medication-related risks and readmissions in the home care setting. Medication errors or events can be introduced by a number of factors, including:


* Polypharmacy-that is, number of drugs


* Medication regimen complexity-that is, complex dosing, administration, or instructions


* Use of high-risk medications such as insulin, oral hypoglycemics, warfarin, and antiplatelet agents



Use of potentially inappropriate medications confers additional risk to older patients, and medication regimen complexity is associated with five times higher risk of an unplanned 30-day readmission (Schoonover et al., 2014). There are some promising findings that automated review of medications with risk scoring and interventions (Olson et al., 2014), or pharmacist-driven interventions (Kalista et al., 2015; Kilcup et al., 2013) can reduce readmissions. There is little evidence of the impact of an interdisciplinary pharmacy collaboration in home healthcare.


In 2014, the VNA Care Network of Worcester, Massachusetts (VNA), decided to focus on reducing medication-related causes of hospital readmissions. The Centers for Medicare and Medicaid Services (CMS) reports that 11.3% of patients who have an Outcome and Assessment Information Set (OASIS) assessment are readmitted (2015). At the VNA Care Network, the CMS-reported readmission rate is 11.9%. With so many patients on complex drug regimens, and pressure to reduce readmissions, the agency decided to augment its interdisciplinary approach by adding a geriatric pharmacist to the care team.


The VNA is part of the integrated health system called Atrius Health. As part of an integrated system, quality improvement activities that address readmissions make business sense in addition to meeting quality and patient goals. Investments in quality care that cost more to deliver can still add value system-wide by reducing inpatient costs. Although pharmacist services are not reimbursable in home care settings, the VNA is testing whether reduced readmission costs can offset the administrative costs of geriatric pharmacist services and add value to the health system overall. The VNA's program uses a specialized geriatric home healthcare pharmacist to help home care nurses address priority medication teaching and safety areas. The pharmacist also develops more effective ways to engage primary care providers (PCP) in discussions of patient medication management.


Under the current project, the VNA's pharmacist reviews all home care referrals from inpatient care for whom the PCP is a participating Atrius medical group member. Any patient taking high-risk medications is selected for the program, as are patients with high medication regimen complexity. The pharmacist performs drug reconciliation to ensure that preadmission medications, facility discharge instructions, and home medications are all accounted for. The VNA's geriatric pharmacist:


* Applies a Medication Regimen Complexity Algorithm to generate a risk score that prioritizes the patient for intervention


* Initiates communication with PCPs and VNA nurses


* Makes recommendations to simplify medication management for the patient


* May recommend lower risk medication regimens or safety precautions to mitigate risks


* Collaborates with nurses and other clinicians to identify high-priority issues for patient teaching


* Interfaces with pharmacy records and physicians in the Atrius system to implement recommended medication changes


* Ensures recommendations are implemented and follows the patient for 30 days



Promisingly, the VNA has seen important initial reductions in readmissions for patients in the program. The VNA compared the first 150 patients enrolled in the program with a group of 100 patients eligible for the program but not enrolled due to space limitations. Both groups were high-risk due to recent hospital discharge and a high medication risk score and had higher than average rates of admission. During the pilot test, the comparison group had a 30-day readmission rate of 23%. The geriatric pharmacist intervention group had 15% readmitted in 30 days (23 of 150 patients). Adding to the impact, 7 of the 23 patients in the intervention group were actually readmitted before the pharmacist was able to conduct a review or intervene. If these were excluded, the readmission rate would be 10%.


Evaluation of the VNA Care Network geriatric pharmacist program is still under way. The evaluation is also examining sustainability of the program overall given that reimbursement for pharmacist services is not available. In addition to impacting readmissions, the agency hopes to see gains in medication-related performance indicators-medication reconciliation and patient report on medication education.


This case example shows the potential for targeted interdisciplinary clinical collaborations to reduce risks for home care patients, and possibly reduce hospitalizations. By focusing on intensive interventions for a group at high risk due to medication-related issues, the VNA is working to mitigate a significant root cause factor in readmissions. This type of specialty service will be attractive to both patients and payers as they seek innovative solutions to reducing potentially preventable 30-day readmissions.




Alliance for Home Health Quality and Innovation. (2014). Home Health Chartbook: Prepared for the Alliance for Home Health Quality and Innovation. Retrieved from[Context Link]


Centers for Medicare and Medicaid Services. (2015). OASIS Outcome Based Quality Improvement Reports. VNA Care Network.


Kalista T., Lemay V., Cohen L. (2015) Postdischarge community pharmacist-provided home services for patients after hospitalization for heart failure. Journal of the American Pharmacists Association, 55(4), 438-442. [Context Link]


Kilcup M., Schultz D., Carlson J., Wilson B. (2013). Postdischarge pharmacist medication reconciliation: Impact on readmission rates and financial savings. Journal of the American Pharmacists Association, 53(1), 78-84. [Context Link]


Olson C. H., Dierich M., Westra B. L. (2014). Automation of a high risk medication regime algorithm in a home health care population. Journal of Biomedical Informatics, 51, 60-71. [Context Link]


Runganga M., Peel N. M., Hubbard R. E. (2014). Multiple medication use in older patients in post-acute transitional care: A prospective cohort study. Clinical Interventions in Aging, 9 1453-1462. [Context Link]


Schoonover H., Corbett C. F., Weeks D. L., Willson M. N., Setter S. M. (2014). Predicting potential postdischarge adverse drug events and 30-day unplanned hospital readmissions from medication regimen complexity. Journal of Patient Safety, 10(4), 186-191. [Context Link]